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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Instaliation Company Name and Cantact Info: Q u � Z ��S — �� <br /> Dale Backwaler Prevention device(BWD)was instalied: � �Date this form was completed: �—�'—�S <br /> Installation Property Owner Name and Conlacl info:��o-�-i-'P1�7 11'L�'1.'��� �,`� 't��2� I <br /> Property Address: I OC�Z (�[��� � '��✓� <br /> Pre•Instaliation Inspection Checklist: <br /> All ilems must be checked'Yes'in order lor a 8WD to be considered l�r insfallation <br /> Is there a basement or tevel o(ihe house thal is al or near assumed sewer main elevaGon? es ❑No <br /> Are there fixtures in the house located 6elow the upstream sewer manhole rim eievalion?[�s ❑No <br /> Is the side sewer curtently UNPROTECTED from sewer backups(does nof have a BWD instalied)?� ❑No <br /> Site Inspeetion Checklisl: <br /> All items must be checked'Yes'before inspeclion is considered complele <br /> Was side sewer N inspected trom building to sewer main? �s ❑No Condilion: U�l g l`�-Q- (��1"�� � <br /> Does side sewer have at least 1%slope from the building to sewer main? m� ❑No Deseribe; <br /> Have all building sewer drain conneclions to lhe side sewer been ident�ed and located? [��es ❑No <br /> Have all propery stortn drainage connedions to lhe side sewer been identified and lorzted? �Yes ❑No <br /> Has property been evalualed far drainage deficiencies wilh findings communicated to property owneR []1`�❑No <br /> Installation Delails: n���L <br /> What type and brand o(BWD was inslalled at this site( ean Check 8VN/,G nder pump,elcJ: l " <br /> Where was lhe deviee inslalled�general description,atlech map 4 P�✓� ��0' . <br /> Was there any other sewer or slortn drainage woric�r��pleted in wnjunclion wilh ihe BWD work?Is so please describe:_ <br /> / nD <br /> InsWllation Checklist: <br /> Are all downspouls and site drainage disconnected trom upstream oi the BW�? 1. s d No Commenls: <br /> Daes 8WD positioning meels minimum siope requirement ot>t%7 �� ❑No Comments: <br /> Can BWD be pulled oui for inspeclion and main�enance atter loosening lhumb screw? [l�-1'e!� �No <br /> is 8WD locked inlo the proper position and re�w lighlened'T �j�.l'esr(]No <br /> Circle ihe 8WD cover:irrigalion er(landscape area �t'raffic load bearing cover(drive surtace)/access hatch(6uilding) <br /> Was praperty owner shown the IocaGon of the instatled BWD? [�Nc�No Comments: <br /> Properly Owner's Signalu . � Date: - ` —�—�s <br /> ' �-'7-/� <br /> Installers Signalure: Date: <br /> Revision: 2 1 Friday,September 12,2014 <br />