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i <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CH�CKLIST ; <br /> p � <br /> � <br /> � <br /> Installatien Company Name and Conlact Irno APo/ /ai,g�,,, j <br /> Dase Backwaler Prevention device(BWD; was installed: �2G/i � <br /> ���Date ;his (orm was compie+ed 2�.�I <br /> I^stallation Property Owner Name and Contact Info.,7en„ ��'o.� T�s�nr/ � <br /> PropeRy Address:-�7/.� ���u y— �r iGnn � <br /> � <br /> Pre-Installation Inspection Checklist: � <br /> A!1 ite.Ts mus!De checked'Yes'm order for a BWD to be considered fa installation ' <br /> is !here a ozsement or level ei,he hcuse that is at or near assumed sewer main eievation?[�}'Yes ❑ No � <br /> Are fhere nxlures in the house loated below the ups!rzam;2wer ma,�hole rim eleva;icn?�]Yes ❑No ` <br /> !s the side sewer currently UNPROTECTED frem sewer oackups (does no( h;ve a BWD installed)?�]Yes ❑ No � <br /> Site Inspection Checklist: <br /> i <br /> AI!rtems must be checked'Yes'6efore inspectron is considered comp!ete i <br /> Was side sewer N inspectetl from building to se�ver main? �Yes ❑ No Condi?ion: <br /> D�es side sewer have at least 1%sioge from the building to sevder main? �Yes ❑ No Describe: i <br /> Have ali building sewer drain connections to the side sewer been identified and located? ,�Yes ❑ No ; <br /> Have aA property storm drainage connections to the side sewer been identified and located? �/]Yes ❑No � <br /> Has property been evaluated for drainage deficiencies with findings communicated fo property owner? �'Yes �No j <br /> Installation Details: <br /> What type and brend of BWD was installed at thi;si ean eck Grinder pump,etc.): ' <br /> bNhere was the device instalied(general desenotion, attac m�_ cc%n`�i �=an�� /�.,�> ; <br /> �p • n <br /> ✓r � <br /> + <br /> VVas there any oiher sewer or storm drainage work completed in conjunciion wi-�ihe BWD ero;k? Is sa p.�;� �;;,�,_,.: ' <br /> � — <br /> Installation Checklist: <br /> i � <br /> I kre all downspouts and site drainage disconcected from upsfream of the BWD? �Yes ❑No Comments: <br /> � Does BWD pasitioning meets minimum slope requirementof>1%? (�Yes ❑ No Comments: <br /> Can BWD b2 pulled out for inspection and maintenance after foosemng thumb screw? �'Yes ❑No � <br /> iIs BWD locked inlo the proper position an�W tightened? [�'Yes ❑No ; <br /> I Circle the BWD cover 'cAgef omn�'v"' a '/traffic load bearing cover(drive surfaca)/acaess natch(building) � <br /> Was property owner shown khe lo lfotrofthg-Irt , ) � Yes ❑ No Comments: � <br /> � ,� ; <br /> � <br /> i Property Owner's Signa re: Date: 2�/7�iS' <br /> � Installer's Signatu _ ! <br /> --..__�—_.-- <br /> -- Date: 2�/J / � <br /> � Revision: 2 1 Monday,September 15, 201G i <br /> � ! <br /> � � <br />