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I <br /> BACKWATER PREVENTION DEVICE FINAL ' <br /> INSTALLATION CHECKLIST <br /> � <br /> Insta!latinn Company Name antl Conlad Into:��" \�� <br /> Dato Backwaler Prevention device(BWD)was instalied: 'b• 1 � � Date fhis form was completed: � �� <br /> Instalistion Property0wnerName and Contacl In(o: t r�.�� � C �-ri,_iacni�5c��� _�._ <br /> PropertyAddress: �,'�''i-�.�� ( ('��n� `�� — <br /> Pre•Installation Inspectlon Checklist: <br /> /+A ifems must 6e checdod'Yes'rn order for a BIND!o bs conside�ed for installation <br /> Is there a basement or lovel of the house t�2t Is at or near as�umed sewer main elevat(on1 [�1'es ❑ No <br /> Are there fixtures in ihe house located below the upstream sewer manhole nm elevation?(�]Ye� ❑ No <br /> Is ihe side se��rer currently UNPROTECTED from sewer backups (does not have a 6VJD Installed)7[�Yes ❑ No <br /> Site Inspection Checklist <br /> All ifems must�e r.heckod'Yes'belore insper.tion is considered compfete <br /> Was side sewer N inspected irom building to setver mafn? � Yes ❑No Condition:__ __—_ <br /> Does side sewer have at leasl 1"/o slope(rom ihe building to sewer main? [�j Yes ❑No Describe: <br /> Havo all building sew•cr drain connedions to tho side seu�er been Identifled and la�xted7 �]Yes ❑ No <br /> HavQ all properfy storm drainage wnneetions lo the side sev,er been identlfied and locat��d7 [�Yes ❑No <br /> Has propsrty been evalualed for drainage deficiencies with fndings communicated to property o�vner7 �Yes L�] IJo <br /> Installatfon Defails: ,�--� <br /> What h�pe and brand of BWD was instailed al lhis si�(Clean Checfc BVIN,Gdrvic��pump,eta): <br /> Where eras the d?vice installed (general desr.ription,allach map)? �t�t.�S�(at d��'✓ �'�� '���- <br /> Was there any other sewer or storm drainage work compl^ ' conjunotion with the OWD work? Is so please describe:_ <br /> Insfallatlon Checklfst: <br /> Are all downspnuts and site drainage disconnecled irom upstream of lhe BWD7 �]Yes L�1 n�o Comments: <br /> Does BWD positioning meels minimum slope requirement of>t%? � Yes ❑No Comments: <br /> Can BWD be pul��d out for inspeclion and maintenance afler loosening lhumb screw7 �Yes [�No <br /> Is BWD locked into the� . posdion an- d(fiu�bsc�w tightened7 �Yes ❑No <br /> Circle lhe[i6VD cov�irri�ation covor(landsppaarea}�Ualfic load bearing cover(drive surtace)1 accoss halch(building) <br /> Was property owner shown the localion of Ihe installed BWD? �Yes ❑No Commenls:__ <br /> Property Ovmer's Signafure: � "- Date: _— <br /> Installer'sSign�ture:T_ ___�____ Dafe��__�I S _ ____ <br /> Revislon�7 � "� 1 Friday,'^ptemhcr l),2014 <br />