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I <br /> 1 <br /> BACKWATER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKLIST � <br /> I <br /> Installation Company Name and Confact Into:/���//� !�/t-n�l�S,a 35 7 - /-S�7 - — I <br /> Date Backwater Prevention devico(BWD)was installed:_�f 3(�i T Date this form was completed: �y ///S� i <br /> � i <br /> Installation Property Owner Name and Contact info: 13r'l/ M�/ltr�Jo�h �`�`��H lo�k �,�r� �vN s � , <br /> PropeAy Address: 2�"1 .��kr� A�v�;. ; <br /> Pre•In�tallatlon InspecUon Checklist: � <br /> All ilems must be checked'Ves'in order for a BWD to be considered for installafion � <br /> Is ihere a basement or level of lhe house that is at or near assumed sewer maln elevation9[�Yes ❑No '. <br /> Are there fixtures in the house located bebv�Ihe upstream sewer manhole rim elevation?�Yes ❑ No I <br /> Is ihe side sewer wnenlly UNPROTEC i ED`rom sewer backups (does not have a BWD installed)9[�Yes ❑ No � <br /> Site Inspectlon Checklist: � <br /> � <br /> All items must 6e checked'Yes'be/ore inspection is�onsidered complefe <br /> Was side sewer N inspected from building to sew::r main? �]Yes ❑ No Condition: ; <br /> Does side sewer have al least 1%slo,r,e from the building to sewer main? (�]Yes ❑ No Descnbe: <br /> Have all building sevrer drain connections to the side sewer been iden6fied and located? [�Yes ❑No ; <br /> Have all property stortn drainage connections to the side sewer been fdentified and located7 �Yes ❑ No ' <br /> Has proporty been evaluated for drainage defic(encies with findings communicated to property ownef7 �[]Yes ❑No � <br /> Installafion Details: ' <br /> Whal type and brand o(BIND was installed at lhis sit eck B , rinder pump,etc.)� ' <br /> � I <br /> Where vras Ihe device installed(general description,a ac map . dac��kG �� /2 •,�.r ��oa.r� <br /> � <br /> Was lhere any oth�r sewer or storm drainage work completetl in conjuncGon v�ilh(he BWD work?Is so please describe�� � <br /> N� <br /> Installalion Checklist: <br /> Are all dov,�nspouts and site dralnage disconnected from upsiream of fhe BWD7 [�Yes ❑ No Comments: ; <br /> Does BWD positioning meets minimum slope requirement oi>t°/a7�Yes ❑ No Comments: <br /> Can BWD he pulled out fur inspection and maintenance afler loosening Ihumb screvJ.��Yes ❑No <br /> Is BWD locked into the proper position�nd,�u �v fi�htened? �Yes ❑No � <br /> Circle the BWD cover�: ion cove�dscape area�j iralfic load bearing cover(drive suriace)1 aaess hatch(building) � <br /> Was properry owner sho�m—the-locatiorf e installed BWD7 [�Yes ❑No Commenis: <br /> / � <br /> PropertyOwner'sSig ! /� �,'�_ Date: 3�.s'/li� : <br /> InstallersSignatu : ` __— Date: 3�3��/� <br /> Hevision:2 1 Friday,Septembcr 12,2014 � <br /> � <br />