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� <br /> ( <br /> BACl61119�41�E8� P9tEVENTIOfV DEVICE FINAL � <br /> INSTALL��'ION CHECKLIST ! <br /> i <br /> Installation Company Name and Contact Info: M 0(/� Pr�..ti�i�'r../ �-/�- � 7G O �3`� <br /> Dafe Backwater Prevenlion device(8WD)was inslalled: �"�'e1 a -f(,' Date this form was wmpleted: y "�'� –f S^ <br /> insfallafion Property Owner Name and Contact Inio: Cd.�� r'7 c�r.a �.�� <br /> Property Address � S�I � (Iti k-*-/ �� i <br /> Pre-installetlon lespection ChnckNst: I <br /> All it•^�s must be checked'Yea'in oruer for a BWO lo be considered!or instellafion � <br /> Is fhere a basemenl or level of the house that is al or near assumed sewer main elevation7 �Yes [� No ; <br /> Are lhere fixtures in the house located below lhe upstream sewer menhole rim elevation7(�Yes [�No � <br /> Is the side se��-er currently UNPROTECTED from sevder backups(does not havo a 8WD installed)? x�Yes ❑No ( <br /> Site InspecUon Checkllst: � <br /> All Nems must be chucked'Yes'before inspecflan is consldered complefe � <br /> Was side sewer N Inspected hom building to sewer main? �Yes ❑No Condi6on, �U�- ; <br /> Does side sewer have at leasl 1%slope from ihe building to sewer main? �Yes ❑No Describe: ; <br /> Havo all building sower drain connec�.,ns lo the side sewer been fdentified and located? �Yes ❑ No � <br /> Have all property storm drainage conneclions to lhe side sewer been identified and Iocaled? �Yes ❑No + <br /> Nas propQrty been evaluated(or drainage deGciencies wilh iindings communicated lo property owner? �Yes ❑No , <br /> Installation Detalls: ' <br /> G•.n �e.5 !w� H..,/Z 1 <br /> What lype and brand of BWD was installed al ihis site(Clean Check BWV,Grinder pump,etc.): � 1�_ � <br /> Wheie was the device installed(general desr.dption,attach map)? (�sc�a,���d ti� h a:N a.-- ��r j <br /> S�z (5 � <br /> I <br /> VVas ihero any ofher seweror slorm drainage work compleled in wnjunclion wilh the BWD work? Is so pleaso descnbe:_ � <br /> �/p � <br /> InstallaUon Cheekllst: � <br /> Are all downspouls and site drainage disconnected trom upslream of lhe BWD7 �Yes ❑No Comments� � <br /> Does BWD posftioninq meets minimum slope requiremenl of>t%? �Yos ❑Nn Comments: <br /> Can BWD be pulled oul for inspeclion end maintenanco after loosening thurnb screw7 ❑Yes ❑No f <br /> Is dWD locked into Ihe proper positfon and thumb screw lighlened7 ❑Yes ❑No � <br /> Circle ihe BWD cover: irrigation cover(landscape area)!lraffic loed bearing cova; (drive surface� 'access hatch(huilding) � <br /> Was property owner shown ihe Iocation of the Instailed BWD? �Yes [�No Comments:_ ; <br /> Property Owner's Signalure: Date: I <br /> �nsfaller's Signalure: / �`-'�— Dato: �-1–�a' f f � <br /> Revision:2 1 Monday,September 15,2014 � <br /> i <br /> i <br />