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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Confact Info: ✓�f1 d�U ��`-�w' b��r,� <br /> Date Back�vater Prevention device(BWD)v,�as Installed: � � � " I � _Date tnis form was completed: (o-�Z�I S <br /> InsiallaGoi Propedy O���ner Name and Coniacl Inio: �C���� �. �-�� �'�S ���S �z�n _ <br /> ProperiyAddress: 13 1 ' <br /> Pre-Installation Inspection Checklist: <br /> All items must be ch°cked'Yes'in order for a BWD to 6e consider�d for installation <br /> Is there a basement or level of fhe house that is at or near assumed sevrer main elevalion?�Yes ❑No <br /> Are there fuctures in the house locatetl belo�v the upstream sewer manhole rim elevation7(�]Yes ❑No <br /> Is the side sewer currently UNPROTECTED irom sewer backups(does not have a BWD instaliad)1�Yes ❑ho <br /> Site Inspection Checklist: <br /> All items must tre checked'Yes'betore inspection is considered compfete <br /> Was side sewer N inspected frvm builtling to sewer main? [�]Yes ❑ No Condifion: <br /> Does side sewer have at least 9%slope from the building to sewer main? �Yes ❑No Describe: <br /> Have all building sewerdrain connections to ttie side sewer been Identified and located? [�Yes ❑No <br /> Have ail property storm drainage wnnections to the side sewer been ideniified and located7 [�Yes ❑No <br /> Has properly been evaluated for drainage deficiencies wilh findings communicafed to propeity on�ner7 [�Yes ❑ No <br /> Installation Details: <br /> What type and brand of BN�D was installed al this site ean Check BNN, Gr der pump,etc.}: <br /> Where was ihe device installed(general description,attach mapj7 � � h'� - i� -� `� � <br /> 5� k ' .t ,F c� <br /> Was fhere any othecsewer or sform drainag�r�ompleled in conjunc6on wilh ihe BWD work?Is so please describe:.� <br /> Installa6on Checklist: <br /> Are all downspouts and site drainage dlsconnectetl irom upstream of the BWD? �f Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement of>t%7 �Yes ❑No Ccmmenis: <br /> Can BWD be pulled out for inspeclion and maintenance aRer loosening umb screw7 [�Yes ❑ No <br /> Is BWD locked into the pr e�siNon-amilhomtrsc►etix6 hlened? �Yes ❑No <br /> Circle the BWD cover.'rrig oa nli cover(Iantlsca raffic load bearing cover(drive surface)1 access hatch(building) <br /> Wes property owner sho�m e ocalion of the installed BWD7 �Yes ❑No Comments: <br /> Property OwnePs Signature: _ Dafe: <br /> Installers 5ignature: Dafe: ��I � 3 � � 5 <br /> �. <br /> Revislon:2 1 Friday,September 12,2014 <br />