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BACKWATER PREVENTION DEVICE FINAL <br /> �� INSTALLATION CHECKLIST <br /> Installahon Company Name and Contacl In(o: c�s ri.um�iNc a seHvice ur,aso e��-5�ss <br /> Dale Backwaler Prevention device (BWD)was installed: Dale this form was compleled: <br /> Installation Properly Owner Name and Conlacl Into: <br /> Property Address �����G� � <br /> Pre•Insfallation Inspection Checklist: <br /> All ifems must 6e checked'Yes'in order lor a BWD fo be conside�ed lor installation <br /> Is�here a basement or level oi Ihe house Ihat is al or near assumed sewer main elevalion?(/�Yes ❑ No <br /> Are Iherc lixtures in the house located below Ihe upslream sewer manhole rim elevalion?r�Yes ❑` ,/No <br /> Is Ihe side sewer currently UNrROTECTED Irom sewer backups(does not have a BWD installed)� �1 res ❑ No <br /> Site Inspection Checklist: <br /> All ifems must be checked 'Ves'6elore inspecfion is considered complele <br /> Was side sewer TV inspected trom building lo se�ver main? es ❑ No Condilion OI� (�,w.4 ��� �� <br /> Does side sewer have al least 1%slope from Ihe building to sewer main? �Yes ❑ M� Describe: <br /> Have all building sewer drain conneclions to the side sewer been idenlified and localed? � Yes ❑ No <br /> Have all property storm drainage conneclions lo ihe side sewer been identi(ied and located? (/�Yes ❑ No <br /> Has property been evalualed for drainage deficiencies wilh lindings communicated to property owner? �j]Yes ❑ No <br /> Installation Details: <br /> What lype and brand ol BWD was mstalled al lhis sile(Clean Check BWV, Giinder pump,elc ): �✓� >��c�ff�"•uul�s <br /> Where v�as ihe device installed (general descriplion,allach map)7 ��� �� �� � (�b-zi5 <br /> ` v <br /> 1,'Vas ihere any olher sewer or storm drainage work compleled in conjunr.lion wilh the BW\ D work?Is so pleaf's�e describe `_� <br /> ^[�i�.'��u��•i��1—��t ��._\`' 9l�. r� � c C�i" �1C �V1��i...nJ \CC��RC�' �tU <br /> �n�s� �ati�n ChecY�cfist`�' �k, r ,'.I oG' aca ��� Q�pz ( <br /> Are al!downspouls and site drainage A�sr,onnected Irom upslream of Ihe BWD7 [�� Yes �] No Commenis ���'1 ' ,t '"� <br /> Does BWD posilioning mer.ts minimum slope requirement o1>1°/a? �'Yes �I No Commenis: o,� N� �x'u�°' <br /> Can BWD be pulled out tor inspeclion and maintenance aller loosening Ihurnb screw9 �]Yes ❑No <br /> Is BWD locked into Ihe proper position and thumb screw Ughtened? rj}"Yes ❑ No <br /> Circle Ihe BWD r.over. irrigalion cover(landscape area) I Ira(fic load uearing cover (drive surface)I access hatch (buildin9) <br /> N�as property owner shown the location o(ihe inslalled BWD7 �'Yes ❑No Commenls. <br /> -� ,—, <br /> Properly 0wncr's Si ur . � C>,-�-- ��'—%-�' •�-=��<..%� Dale a�' D i l� <br /> ;--� <br /> Inslaller's Signatur 1 �" " Dale. O(�- US— �� <br /> Revision: 2 1 f riday, Srptrmhcr ]7, 7014 <br />