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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />,�►�r, c�n �{+ ��� s�e sc'-��� L LG <br />Installation Company Name and Contact tnfo:T, C.0 Qr�r� /4 a�) •�4! -C�.�.�,Cf� (%; rr1� :'}. ,) ��.�) -.�'.�Jy <br />Date Backwater Prevention device (BWD) v�as installed: �� .^ ' Date this form was completed:���`�-- <br />Installalion Property O�vner Name ard Contact Info: <br />Property Address: <br />Pre-Installation Inspection Checklist: <br />J <br />Ali items must be checked 'Yes' in order for a BVJD fo be considered forins�allation <br />Is there a basement or level ot the house that is at or near assumed see+er main elevation?� Yes ❑ No <br />Are there fixtures in the house located beloef the upstream sewer manhole rim elevation? �Yes ❑ No <br />Is the side se�ver currently UNPROTECTED from sev�er backups (does not have a BWD inslalled)?.j�Z(Yes ❑ Vo <br />Site Inspection Chetklist: <br />All items musf 6e cnecked 'Ves' before inspecfion is considered complete �' i <br />Was side sewer TV inspected from building to sewer main? �Yes ❑ No Condi:ion: �"Lkr _ <br />Does side seva�r have at least 1% slope from ihe building to sewer main? [�..Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and iocated? �Yes ❑ No <br />Have all property storm drainage connections to the side sewer bean idenlified and located7 �Yes ❑ No <br />Has properiy been evaluated for drainagc deficiencies eaith findings communicated to property owner? [�Yes ❑ No <br />Installation Details: <br />What ty�pe and brand of DWD was inslatled at this site (Clean Check "❑'dUV, Grinder pump, etc.): C� <br />Where was the device installed (general descriplion, attach map)? �� GY��('q�.�P� �S �E� <br />lNas there any olher sewer or slorm drainage �vork compl�led in conjunc!ion with the OWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnectec. from upstream of ihe BWD? (� Yes ❑ No Comments: <br />Does BIND posilioning meets minimum slope requirement of >1%? �Yes ❑ No Comments: <br />Can BWD be pulied oul tor inspection and maintenance afler loosening Ihumb screw7 �.Yes ❑ No <br />Is BWD lock: � into the proper position and thumb screv+ tightened? Yes ❑ No (���.�����.. <br />Circle the BN�G cover. irrigalion cover Qandscape area) fiic.load aring cover�c ive'SurTace) / access halch (building) <br />Was property owner shown Ihe location�e inslalled 8WD? � Yes ❑ No Comments: <br />PropeAy Owner's Signature: <br />Installer's Signalure� <br />Dale: � - z ' <br />Date: �oi <br />Revision: 2 � 7 Friday, September 12, 2014 <br />