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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installalion Company Name and Contact Info: � lvvn �JlY1-q �Z((' �IiS "7�`�`G✓Z � <br /> Date Backwater Prevention device(BWD)was installed: " � "'� Dafe this form was completed: ���'�S <br /> Installation Property Owner Name and Contact Info:S�/�J�-c�n i 2- r9-oCo .- ZvS�`� z�o � <br /> Property Address� /�2 ��Lf�`7 <br /> Pre•Installation Inspection Checklisl: . <br /> All rfems must 6e checked 'Yes'in order for a 8WD to 6e considered(or installatron <br /> Is there a basement or level o(the house that is at or near assumed sewer main elevation? es ❑No <br /> Are there fixtures in the house located below the upslream sewer manhole rim elevalion7 es ❑No <br /> Is the side sewer currently UNPROTECTED from sewer backups(dces nol have a BWD installed)?�,]a'es ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'6elore inspecfion is considered compfet �.1���e�,eS-�1 <br /> Was side sewer N inspected from building to sewer main7 es ❑No Condition: C��- - D�-�-(r�-�- <br /> Does side sewer have at least 1%slope irom the building to sewer main? es ❑ No Describe: <br /> Have all building sewer drain conneclions to the side se�ver been identified and located? [�'� �]No <br /> Have all property storm drainage connecfions to the side sewer been identified and located? �'rTes ❑No <br /> Has properiy been evalualed for drainage defciencies wilh findings communicated to property owneR 0'fE�"0 No <br /> Installation Detaiis: Cn/� /� � ` <br /> What type and brand of BWD was installed at this sile lean Check BW/,Grinder pum ,�elc.): �-f�Gftc.d <br /> Where was lhe device installed(general description, altach map)? -Y-�� �✓� �.JQ� - <br /> Was there any olher sewer or slortn drainage work complete in conjunclion with the B work Is so please describe:_ <br /> �/ ,�D (��:OUz`9�S • <br /> Installation Checklist: <br /> Are all do�vnspouls and site drainage disconnected from upsiream oi lhe BWD? es ❑No Commenls:��Q� � <br /> Does BWD positioning meels minimum slope requirement of>1%? es ❑No Comments: <br /> Can BWD be pulled out for inspe�tion and maintenance afler loosening Ihumb screw? �N�(] No <br /> Is BWD locked into the proper position an e,w lightened? es ❑ No <br /> Cir�le the BWD cover:irrigalion co landscape area).l�traffic load bearing cover(drive surface)I access hatch(building) <br /> Was property owner shown Ihe localion oi the installed BWD7 �a'es�Q No Commenls: <br /> PropeRy Owner's Signature� � _ Date: g ��r <br /> ' Installer's Signature: Date: ��'1 .�� <br /> Revision:2 1 Friday,September 12,2014 <br />