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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ��r r ..}(:;r11 <br /> Installation Company Name and Contact lnfo ��� ' }�' `-''.'�I- � `�"�-�u�r 5�` rr��, �( �'l�G'��;:':'"�..,�;;1 <br /> Date Backwater Prevention device(BWD)was installetl��_Date Ihis torm�vas completed: � g <br /> Installa�ion Property Owner Name and Contacl In(o:��V _�1�1L�.�—'T`���-� ��-�-`t� <br /> Property Address: a�1 {� �1"�/`u<�Y1--��1���� Q-�a U — <br /> Pro•Installation Inspection Checklist: <br /> All ifems must be checked 'Yes'in order�or a BWD lo be considered fa installation <br /> Is there a 6asement or level of Ihe house ihal is at or near assumed sewer main elevation? �Yes ❑ No <br /> Are ihere lixtures in the house localed betow Ihe upstream sev:er manhole rim cleval�on?� Yes ❑ No <br /> Is the side sev;er currentty UNPROTECTED frem se���er backups(does not have a BWD installed)? ��Ves ❑ No <br /> Site Inspeclion Checklist: <br /> All items must be checked 'Ves'be(ore inspechon is conside�ed complefe /� <br /> UVas side sev+er TV inspecled trom building to see�er main? �Yes ❑ No Condition __1:,��(�[�__.._ <br /> Ooes side se�ve, have at teast 1%slope(rom ihe building to sewer main? [�Yes ❑No Descnbe: <br /> Have all building se�ver drain conner.t�ons to the slde sewer been identified and located7 �yes ❑No <br /> Have all property storm drainage conneclions ro ihe side sewer been identified and located? �Yes ❑ No <br /> Has property been eva�uated for drainage de(iciencies�vith findiogs communicaled to property o�vner? [�Yes ❑ No <br /> Installation Oetails: /� f � <br /> What type and brand of BWD�vas insialled at Ihis site(Clean Check BWV, Grinde�r�pu� mp,etc.): t'�N StU�� <br /> Where�vas the device installed (general description,afla�h map)'? `7C',N .0 r r[C-1S���_ �S_�1.�-7� <br /> Was there any olhr.r setiver or storm drainage w•ork completed in conjunction wilh the DWD v�ork7 Is so please describe:_ <br /> - -- - - - ---- ---��c�(-U1 -- — <br /> Installation ChecMlist� <br /> Are all do�vnspouls and site drainaye disconnected Irom upstream o(lhe BWD? �Yes L�No Comments� _ <br /> Does BWD positioning meets minimum slape requirement of>1%? �Yes �� No Commanls _ _ ____ <br /> Can BVJD be pulletl out for inspection and maintenance afler loosening Ihumb screw7 �f( Yes ❑No <br /> Is BWD locked inlo the p�o er�ition and thumb screw ligh�ened? �Yes ❑ No <br /> Circle the BWD cover irriUation cove landscape area)I traffic toad beariny cover(drive surface)1 access halch (building) <br /> Was properly owner sho�vn Ihe location of lhe instatled BWD? �]Yes [� No Comments <br /> i� . � <br /> Prope�ly O�vnor's Signature• ��r-u�-^- Date: ' <br /> Inslaller's Signature: _� __ Date:� � I <br /> I <br /> Revision:2 1 Friday, September 12, 2014 <br />