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BACKWATER PREVENTION DEVICE FINAL <br /> �• INSTALLATION CHECKLIST <br /> Installalion Company Name and Contact Info: 5 '� r � � +�-i S�° �,.•-• �- I^' �- N Z� - `II�f� ���l Z <br /> Dale Back�vater Prevention device(BWD)v+as installed � I 5 - J�Date ihis lorm�vas completed: '-1 - � L� � �L� <br /> L�stallalion Property Owner Name and Cor�act Info �,E�� i 5 _ L�2 � - 3�;� -G� 3 S`'� <br /> Prnperty Nddress:�(. I lr _ 1�/1 K-�C'� ��V� <br /> Pre•Installation Inspection Checklist: <br /> All itenu must be checked 'Yes'in order lor a 6VVD fo be considered lor ir„tallafir,n <br /> Is there a basement or level of the house that is at or nea assumed sewer main elevalion?[Ycs ❑ IJo <br /> Are there fiztures �n the house located he�o�v ihe upstream sev+er manhole rim el?•,ation?�Yes ❑ No <br /> Is ihe side sewer currenlly UNPROTECTED (rom sewer backups (does not have a BV��D installe,i 'G(�1'es [� No <br /> Site Inspection Checklist: <br /> Ail items musf be checked 'Yes'be%re inspscfion is considered complete <br /> i <br /> lNas side sewer TV inspected(rom building ro seiver main? �Q Yes [_� No Condition: �u�•��� _ <br /> Does side sewer have al least 1%s�ope irom the building b sewer main? �]Yes ❑ No Descr�be:_.____ <br /> Have a!I building sewer drain connecfions to Ihe side se��er been idenCfied and located7 j] Yes ❑ No <br /> Have all property slorm drainage connections to ihe side seerer been identified and locaeed? [x�Yes ❑ No <br /> Has properly been eva!vated for drainage defic�encies e�ith f�ndings communicaled ,o property oer�er7 (� Yes ( ; No <br /> Installation Details: <br /> What lype and brand o�BWD�vas installed al ihis sit (Clean Check BWV�Grinder pump, etc) __ <br /> INhere was the device inslalled (general descnp�ion, atlach map)? g.�f�-+<„. f/l� � li o.,5 e �,,,.-� <br /> c� I� L'_� � i`.. ._(:f �'�_i S (� F� 1-nCr_(.e�7�W ��_.l��'e,.�I- ,,T Al�('Wnfr n'� � n,.S,.4 <br /> T <br /> 1Nas ihere any n!her se�ver or storm drainage work completed in conjunchon wilh the BWD�vo�k?Is so p�ease dr.scribe _ <br /> — `) -`-� — — — <br /> Insiallation Checklist: <br /> Are all downspouts and site drainage disr.onnected from upstream ol Ihe BWD? (� Yes ❑ No Comments: <br /> Does BWD positioning meels miniinum slope requirement of�1°�? UC]Yes � _] No Comments __ <br /> Can BVdD be pidled oul for inspection and maintenance afler looseniag Ihumb screw? � Yes ❑ No <br /> Is BWD lockod into Ihe pro er posi�inn and thumb screv�lightened? f�Yes ❑ No <br /> Circ'e Ihe BWD covc irrigalion voc e (landscape area)1 traffic load bearing cover (drive surface)I access hatr.h (buildriy) <br /> 11�as propedy owner shown Uie locahon of t �stalled BWD'? Yes ❑No Commenls. <br /> Propehy O�vner's Signalure Dale ��� ^�� <br /> Instailer's Signature: /L /-5-��L _ Dale 1� ' 1� " �� <br /> �— _ - - - <br /> Revision�. 2 1 Friday,Sep[ember 12, 20i4 <br />