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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: �'J�11 � `'`�-�`��r\^� <br /> Date Backwater Prevention device(BWD)v�as inslalied: (n "\2 - 1 S Date this form was completed: Co - f�-��� <br /> InstallaGon Property Owner Name and Contact Inio: �c�� � eT� �-I -� u�- ��`���'e- <br /> PropertyAddress: �'��'' ��U�>o`� �1vc� � <br /> Pre•Installatlon Inspection Checklist: <br /> Afl items musf 6e checked'Yes'in order for a BWD fo be considered for installa6on <br /> Is chere a basemenf or level of the house that is at or near assumed sewer main elevation7[�]Yes ❑No <br /> Are there fixlures in the house locafe d below the upslream sewer manhole rim elevafion?[�]Yes ❑No <br /> Is the side sewer currenUy UNPROTE'CTED irom seveer backups(does not have a BWD installed)7 �Yes ❑ No <br /> Site Inspectlon Checklist: <br /> All ifems must be checked'Yes'6e(ore inspection is considered compfete <br /> Was side sewer N inspected irom building to sewer main? [�Yes ❑No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main7 [�Yes ❑No Describe: <br /> Nave all building sewer drain connections lo the side sewer been identi6ed and located? [�Yes ❑No <br /> Have all properly slortn drainage connections lo Ihe side sewer been IdenUfied and located? L11 Yes ❑ No <br /> Has properly been evalualed for drainage deficiencies wilh findings communicated to property owner7 �Yes ❑No <br /> Installation Details: <br /> What type and brand o(BWD was inslalled ol this site( lean Check B , Grinder pump,etc.): <br /> Where vras Ihe device inslalled(general description,attach map)1 ����P-W�� <br /> Was there any other sewer or storm drainage vror���mpleled in conjunction wilh Ihe BWD work?Is so please descnbo:_ <br /> Installation Checklist: <br /> Are all dovrnspouls and site drainaye disconneeted from upstream of ihe BWD? [1�]Yes ❑No Commenis: . <br /> Ooes BWD positioning meeU minimum slopn requiremenl of>t%7 �Yes ❑No Commsnls: _ <br /> Can BWD be pulled out for inspeclion and mainlenance afler loosening ihumb screw7 (�]Yes ❑ No <br /> Is BWD locked Inta lhe proper posilion and lhumb screw Ughlenedl Y��No______� <br /> Circie lhe BWD cover. irrig�tion crover(landscape aroa)1� ic load bearingcover driv_e�ace}�Paccess hatch(building) <br /> Was properly owner shown the location oi the installed BlND7 �Yes ❑No Comments: -- <br /> Properly Owners Signalure: � , Date: <br /> Installers Signature:�.j _ Date:��� �2 " ( S <br /> \ <br /> Revision: 2 1 Friday,September 12,2014 <br />