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BACKWA7ER �REVENTION DEVICE FIf�AL <br />INS�'ALLATION CHECKLIST <br />installation Company Name and Contact Info: T �� ,�+u �'� ��� <br />Date Bachlvater Prevention device (6VJD) vras installed: �- 1�-1-1�� Date this form vras completed: �,�-1 S�- +S - <br />Installa�ion Proporty Owner tdame ard Contact In(o: � 1�Ai � ���� � ��� — <br />PropertyAddress �T1�G ��5�" `� <br />Pre•Installation Inspection Checklist: <br />.411 items must 6e checked'Yes' in order for a BWD to be considered /or installstion <br />Is there a 6asement or level of the house lhat Is at or near a�sumed sewer main elevation? [� Yes ❑ No <br />Are tnere fixtures in the house located beloe� the upstream sev.�er manhole rim elevation? [�] Yes ❑ No <br />Is the side sev�er currently UNPROTECTE� from sev�er �ackups (does not have a BWD inst�lled)7 (7f Yes ❑ No <br />Site Inspectlon ChecklisE: <br />All ifems must be checked 'Yes' befare inspecfion is �:onsidered complete <br />Nlas side se�ver N inspected irom building to sevaer main? [�] Yes ❑ No Condifion: <br />Does side sewer have at least 1% slope from the building to sewer mainl � Yes ❑ No Describe: <br />Have all buiiding sewerdrain connecfions to the s(de sevrer been identified nd localed? �] Yes ❑ No <br />Have all properry storm drainage connections to lhe side sen�er been IdEntified and located? [7� Yes ❑ No <br />Has property been evalu�;ed for drainage deficiencies vaitn iindings communicated to property owner' � Yes <br />Installation Details: �� <br />�Nhat type and brand oi BWD �vas installed at this sit (Clean Check B, Grinder pump, etc.): <br />iNhere v;as the device installed (general descripfion, atiach map)? �' 1.�,�.fc� �, ��� E� �^ rl u` <br />❑ No <br />Was there any oiher sewer or storm drainago work compleied in conjunction with the BWD work? is so please describe: _ <br />Insiallation Checklist: <br />kre all downspouts and site drainage discormecled from upstream of the BWD? [� Yes ❑ No Comments: <br />Does 8WD positioning meets minimum sfop� requirementa(>1%? [�] Yes ❑ No Commenfs:,�— <br />Can BVt'D be pulled out for inspection and mainfenance afler loosening thumb scre�v? [�] Yes ❑ No <br />Is BWD locked into the proper posiHon and thumb screv+ 6gh�tened��] Yes No <br />Circle the BWD cover, irrigation cover (landscape area� affic load beanng c__ over (drive sudacaj � access hatch (building) <br />Was property ovaner shown fhe Iccafion of the instailed BIND7 [�] t'es ❑ No Comments: <br />Prop°rty O�vners Signalure: - Daie: <br />, <br />Installers Signature: ^ Da'e: 5'- I S'� 1S <br />Revision: 2 1 friday, September 12, 2014 <br />