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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Instellation Company Name a�Contact Info:� �r lil� <br /> Date Backwater Preventlon devlce(8WD)was Installed: �2���I �y _Date this fortn was completed: 12I I z�� � <br /> Inslalletlon Property Owner Name and Contact Info: 1 )P V ,�A �1��,�,`.1/� <br /> PropertyAddress: � S21�. Co�`�u � <br /> Prednstelletlon Inepecdon Checkliet: <br /> Afl dems musf 6e checked'Yes')n order for e 8WD to be aonsldered for insfaAation <br /> Is there a basement or level of the fwuse ihal Is at or near assumed sewer main elevation?'�Yes ❑No <br /> Are there flxtures in lhe house located below the upstream sewer manhole rim eleveGon?[�Yes ❑No <br /> Is the slde sewer currenUy UNPROTECTED(rom sewer ba,;kups(Ooes not have a BWD installed)?�Yes ❑No <br /> Slte Inepection Checklie� <br /> All items must De checked'Yes'before InspecNon Is oonsldered complete <br /> Was side sewer N inspec�ed from buflding to sewer main7 �Yes ❑No Condition: <br /> Does slde sewer have et leaet 1%slope from the buildlnP to sewer main7 (`�,Yes ❑No Describe: <br /> Have all building sewer dreln connections to tha side sewer been Identlfied and lorated7 �Yes ❑No <br /> Neve all property storm dreinage connectlons lo the slde sewer been Iden6fied end located? �Yes ❑No <br /> Has prooerty been eveluated for drainage deficlencies wifh findings communiqted lo proparty owner? �Yes ❑No <br /> Install�tion Detelle: <br /> What type and brand oi BWD was inslalled at this sfte(Cleen Check BWV,Grinder pump,etc.): �,1 Df�l P <br /> Where was the device Instelletl(generel description,atlech map)7 l%t'� ��f'I A.n a . <br /> Was there any olher sewer or storm drainage work wmpteted in conjunction wilh Ihe BWD work7 Is so please describe:_ <br /> h � <br /> Inst�il�Uon Checkltst: <br /> Are all downspouts and site dralnage disconne�ted(ro�n upstream of lhe BWD? (�Yes ❑No CommenLs: <br /> Does BWD positioning meets minimum slope requirement of>1%9 [�Yes ❑Na Comments:r <br /> Can BWD be pulled out for Inspeclion and malnlenance after loosening thumb saew7 �(Yes ❑No <br /> Is BWD locked into the pro�:�r os lo and thumb saew tightened7 �Yes ❑No <br /> Circle the BWD cove irrigeNon oover(landscape ere UaK�loed bearing cover(drive surface)/ecoess hatch(building) <br /> Was property owner shown the loca6on e nstelled BWD9 �Yos ❑No Commenls: <br /> Properry Owner's Signdture: � r Date: �i� �� <br /> Installers Signaturo: �� _ Date: � Z !Z � <br /> Revislon:2 1 Friday,September 12,2014 <br />