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I <br /> t <br /> � BACKWATER PREVENTION DEVICE FINAL i <br /> INSTALLATION CHECKLIST � <br /> i <br /> ,se FF�1-c�.��(,� ; <br /> �» r �'r '�-S;d, �i1.�.Q1c�CC � ^ ,_'c'�ao8�1.. i <br /> Inslallation Company Name and Cantact Inio: • r'�'i r c�ti�•� ! <br /> �_Date this lorm was completed: 1 i� 4� � <br /> Date Backwater Prevention device(BWO)was installed: I- I <br /> InstallaHon Property Owner Name and Conlact Info: ' �^�'^' �' �"�Y � t�' �r�A f � � I <br /> , y � , �• � 'i'' <br /> Property Address: � <br /> Pre•IneqllaUon InspecNon Checklist: � <br /> All flems must be checked'Ves'in order for a 8WD to 6e consldered for fns�a11:3fion � <br /> Is there a basement or level of the house that Is at or near essumed sewer main elevation?�Yes ❑No j <br /> qre there Oxlures in Ihe house located below the upstream sewc�manhole rim elevation9�Yes ❑No ( <br /> Is the side sevrer currently UNPROTECTED trom sewer backups(does not have a BVJD inslalied)7�Yes ❑No '� <br /> Ske In�pection CheckU�t: I <br /> All Rems musf be checked'Yes'belore inspectan is considered complete i <br /> Wes side sewer N Inspected irom building to sewer malnl ($Yes ❑No Condilion: , <br /> i <br /> Does side sewer have at least 19'o siope irom the building to sewer main? �Yes ❑No Describe:_____.___ � <br /> Have all buiiding sewet drain cwnnectians to the side sewer been Ident�ed and located? �Yes ❑No <br /> Have all property storm drainage connectlons to the side sewer been identified end located7 �Yes ❑No <br /> Has propaAy been evaluated for drainage deficlencles with findings cammunicated lo propedy owner? �Yes ❑No <br /> InstalletionDetails: r�• �U Q-b�,� <br /> What rype and brand ot BWD was inslalled al lhis sile(Gean Chack BVW,Grinder pump,etc.): �` I� <br /> Where was lhe device installed (general description,atlach map)1 �'"" �� I f_.r(h.,,1�T�-k� <br /> Was there any other sewer or storm drainage work completed in conjunction wilh the BWD vrork7 Is so please describe:� <br /> �1c��? <br /> InstNletion Checkllet: <br /> Are all dawnspouls and site dralnage disconnected trom upsheem oi the BWDT �Yes ❑No Commenta: <br /> Does BWD posilioning meels minimum slope requfremenl of>1%9 �Yes ❑ No Comments:__ <br /> Can BWD be pulled oui for inspection and malntenance afler Ioosoning thumb saew? �Yes ❑No <br /> Is BWD lo�ked into the proper posftion and thumb screw tlghtened? �Yes ❑No <br /> Clrcie Ihe BWD cover' igatbn covur landscape area)I traffic load bearing cover(drive surface)I access hatch(bullding) <br /> Was properly owner shown the location of lhe installed BWD? �,Yes ❑No Comments: <br /> Property Owner's SiQnature: �� ti ��4r�� . _ Date: �I'14 "l�{� <br /> � , � Date:�/i/4 �� <br /> Installers Signalure: � <br /> Revislon:2 1 Friday,September 12,2014 <br />