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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> 1'�{`i Cr[n �,�'� i G "Y 5+d e : e.ciX'�'� L LG <br /> Installa6on Company Name and Contact Info:S� r ? �' ' -C • (' , ` /. �� <br /> Date Backwater Prevention device(BWD)was installed:�_Date this form was completed: r3 t.� <br /> Installation Property Owner Name and ContacClnfo:,�5� � � -• <br /> PropertyAddress: 1�� I�;ri�A' �(J�,T_rl��,d,Q, g�a��v <br /> Pre•Installation Inspeetlon Checklist: <br /> All ifems must be checked'Yes'in order lor a BWD fo be considered lor insfallafion <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation7 �Yes ❑ No <br /> Are lhere lixtures in lhe house loca�ed beiow Ihe upstream sewer manhole rim elevalion9 es ❑No <br /> Is the side sewer curtently UNPROTECTEO hom sewer backups(does not have a 9WD i stalled)7 [�1'es ❑No <br /> Site Inspec8on Checklisl: � <br /> Al!items must be checked'Yes'6efore inspection is cansidered complete /'� `` � <br /> _ Was side sewer TV inspected from building to sewer main? �p9 Yes ❑No Condition� C_�71Y}�1 <br /> ("'-°--- _ - --- . ._.. — — . - _ ..._ --- <br /> Does side sewer have at least 1%slope from the 6uilding to sewer main? (�Nes ❑No Describe: <br /> ( <br /> Have all building sewer drain connections to the side sewer been identified and localed? Yes ❑No <br /> Have all property storm drainage connections to the side sewer been idenGfied and locale 7 �Y�s ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicaled!o property dwner? �Yes ❑No <br /> Installation Detsils: <br /> What type and brand of�WD was installed at Ihis sile(Clean Check BWV, Grinder pump,etc.): R .�z{r y� �� <br /> Where was Ihe device installed(general description,attach map)?��_[p���g�iQ�e_J���-� <br /> Was theie any other se�ver or storm drainage work compleled in conjunclion with ihe BWD work? Is so please describe: _ <br /> �. I ,Mn <br /> - --- — - --- ---��c�-`r -- <br /> Installatfon Checklist: <br /> llre atl downspouts and sile drainago disconnected from upstream of the BWD7 �Yes ❑ No Commenls: <br /> Does BWD positioning meets minimum slope requirement o1>t%7 �Yes ❑No Comments:�_ , <br /> Can BWD be pulled out for inspection and maintenance after loosening Ihumb screw? (�Nes ❑No <br /> Is BWD locked in�o the proper posilion and thumb screw tightened? (�Yes ❑ No <br /> Circle the BWD cover ' alion cover(I nbscape area)/traKc load bearing cover(drive sudacej I access hatch(buildmg) <br /> Was property owner shown ihe location of the installed BWD7 �Yes ❑No Comments. <br /> � . � <br /> Property Owner's Signature: batei -3-�'�S <br /> Installer's Signalure: �,�G.� Date: <br /> Revision:7 1 Friday,September 12,2014 <br />