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i <br /> � <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL ' <br /> INSTALLATION CHECKLIST � <br /> � <br /> . � <br /> �►'�'r►c�xr� �F � G �r �� c,��� � 1_c � <br /> Inslal(ation Company Name and Contact In1o�S� L' i rl� (4��a ' `C� Y! • n�v � „�� �y��� <br /> Date Backwater Prevention device(BWD)was insfalled: i l (g '- Date Ihis form was complefed: 1�� I <br /> Installation Property Owner Name and Contact Info: � Z �} � <br /> ProFertyAddress: 1 � � LVEIZ �({iU /�UII rSUL2���� ,fi G�d� � <br /> Pre•Installation Inspection Checklist: � <br /> All ilems must be checked'Ves'in order lor a BWD lo be considered for installa�ion ! <br /> Is there a basement or level o(fhe house that is at or near assumed sewer main elevation7, Yes � <br /> ❑No � <br /> Are there fixtures in the house located belov the upstream sewer manhole nm elevation7� Yes ❑No ! <br /> fs tha side sewer currently LINPROTECTED irom sewer backups (does not have a BWD iAsfalled)?(�f Yes ❑ No � <br /> Site Inspection Checklist: � <br /> All ilems must be checked'Yes'6efora inspection is considered complefe � <br /> Was side sewer TV inspected from 6uilding to sewer main7 �Yes ❑No Condition: � ' <br /> Does side sewer have al least 1%slope irom the buiiding to sewer main? �Yes ❑ No Descri6e: � <br /> Have all building sewer drain connecGons to the side sewer been idenfified and located7 � Yes ❑ No � <br /> Have all property stortn drainage conneclions to Ihe side sewer 6een identified and locate�7 [�Yes ❑No � <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? �Yes ❑ No j <br /> Installatlon Detafls: I <br /> What type and brand of BWD v�as inslalled at this sfte (Clean Check BWV, Gnnder pump, etc.): � � ! <br /> Where was the device installed(general descriplion,attach map)� �p /�O �r-J�n/' S�'J'�'`�� i <br /> � <br /> i <br /> Was there any other sewer or storm drainage�sork completed in conjunction ith ihe BWD work7 Is so piease descnbe: � <br /> -- -- ---------��UYi1 � i <br /> Installadon Checklist: � <br /> Are all downspouts and site drainage disconnectod from upslream of the BWD7 (�1'es ❑No Comments: � <br /> Does BWD positioning mee�s minimum sinpe requirert�ent o(>1%? ��Yes ❑No Commems: � <br /> Can BWD be pulled ouf for inspeclion and maintenance aller loosening thumb screw? �1'es ❑No j <br /> Is BWD locked into the�per.posllion and thumb screv�tightened? �►es ❑No ! <br /> Circle lhe BWD co�r, ir�nyation covec{lan pe a a /tr"c load bearing cover(drive surtace)/access hatch (building) � <br /> NJas property owner s�n the�location ot the ins II BV�. ? �P'es ❑No Comments: � <br /> � <br /> ' ( <br /> Property Owner's Signature: . Oate:_ l/- ((� - /�j ( <br /> installer's Signature:�c� Date: �� — (� - � S <br /> I <br /> Revision:2. 1 Friday, Septem6er 12, 2014 <br />