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� BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST ; <br /> � rr�;r�cun �r;p �G �r �� ��:��r-, �. �c � <br /> Installation Company Name and Contacl Inlo:��•�Qi l�i •�-���.%�n�i��nl� a'.kz)a�)n- �J�C� <br /> tii � <br /> Date Backwater Prevenlion Jevice(BWD)was installed:,����Date ihis form was compleled: . <br /> Installation Propedy O�vner Namc and Contacl Info;_�G��{�� ' �i��Qg_�(r�3 ' <br /> PropertyAddtess: ��fo�LCt� ►^���-�A" f7t—� FIIWA"P� � �� � � ; <br /> Pro•Installation InspecHon Checklist: <br /> All ifems must 6e checked'Ves'in order lor a BWD to 6e considered/orinstallalion <br /> Is there a basement or level o(ihe house Ihal is at or near assumed sewer main elevation�Yes ❑No ; <br /> Are there fixlures in ihn house lor.aletl below ihe upstream sewer manhole rim elevation7 Yes ❑ No <br /> Is ihe side sower currently UNPROTFCTED fram sewer backups(does not have a BWD inslallad)?�Yes ❑No <br /> Site Inspection Checklist: <br /> I <br /> All items must be checked'Yes'be(ore inspection is considered complete /� ' <br /> Was side snwor TV inspectod from 6uildinq to sewer main7 �Yes ❑No Condition:.1,."�C(� ' <br /> Does side sewer have at least 1%slope from the building to sewer main? �Xes ❑No Descnbe: <br /> Have all building sewer drain connections lo the side snv�er bcen identified and lor.aled? �}�'es ❑ No ; <br /> Have all property storm drainage connecUons lo lhe side sewer been identlfed antl located7 [�-Yes ❑ Nu <br /> Has propedy br.en evatuated for tlrainage deficiencies with flntlings r.ommunicated to prr,perty owner? �(es ❑No <br /> Installati^n Detalls: r_-�� n <br /> Whal lypo and brand of 6WD was inslalled at Ihis site(Clean Check BWV,Grinder pum,,etc.): �Y/� ' � <br /> Whcre was lhe devir,e instalhxl(general dr.scriplion,atlar.h map)'t �,b?, �a.'_���<�_� /�.L�t <br /> Was Iher�any other sewer or slom�drainaye work c:ompleted in con unction wilh tho[iWD work7 Is so please doscribe:_ <br /> — --- ,-- -- -- -- — - �n� _.�__— <br /> Instaltation Checklist: ' <br /> Are all downspouts and site drainage disconnected from upstream o(the BWD? �Yes [J No Commanis:�_. ,__, <br /> Daes QWD positioning meels rni�umum slapc requirement of>1"/0? �es � � Nn f.omments: ___ __ ____ <br /> Can BWD be pulled oiA for inspeclion and mainlenance afler loosening Ihumb screw? �xes ❑ No . <br /> Is DWD locked into ihe proper�nsiGnn and ihumh screw tighlr.ned?�o�Yes ❑ No � <br /> Cirdo Uie BNi�cove�rriyaliun coyor(IartJaTape area)I traKc load hearinc�r,over(drive suAace)/ar.cess hatth(bullding) <br /> L__� � <br /> Was propet owner shown Ihc location of lhe inslalled BWD7 �Yes ❑ No CommeNs: _ _._______ <br /> Propo�ly Owncr's Signaturr,: � ,r✓I��7.c- Dale:_]_1�� �� <br /> _ _ �--- - _2�� /� <br /> Installer's Signalure:�---___ '. . _ _ - __ _ _. Date:�___ <br /> _� <br /> ReviSjon: 7 ] friday, Sc��lember 17, 2074 , <br />