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BAC�(WATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> `�GC 4C;r�� <br /> Installation Company Name and Contact Info:���N�1 1,��1 ��~T�"E"���F SP�-��r, «�� ��� ��� <br /> Oate Backwater Prevention device(BWD)was installed:�Date lhis form was completed: la� <br /> Installalion Property Owner Name and Contact Into:'�j���+,�ya� ` ��-a�s. Q8�1 <br /> Property Address: ' "= <br /> . � <br /> PrednsWllation Inspection Checklist: <br /> Ail items must be checked'Yes'in order for a B WD to be considered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?�Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim eleva6on?�Yes -❑No <br /> Is 6ie side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?��i'Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complefe _ / <br /> Was side sewer N inspected from building to sewer main? �Yes ❑ No Condition:�-��f�G __ <br /> Does side sewer have at least 1%slope irom the buiiding lo sewer main? (�'es ❑No Describe: <br /> Have all building sewer drain connectlons to the side sewer been identified and iocated:+ (�'Yes ❑No <br /> Have all property storm drainage connections to the side sewer been iden6fied and located? �Yes ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to properry owner? [�'es ❑No <br /> Installation Details: <br /> What type and brand ot BWD was instalied at this site(Clean Check BWV, Grinder pump,etc.): ���r��Q <br /> Where was the device insialled(generai description,attach map)? ��7[� �� �.r'�P ��1�� <br /> \ <br /> Was there any olher sewer or storm drainage work completgd in co�unclion with the BWD work?Is so please describe:_ <br /> � <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upslream of the BWD7 [�Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement oi>t%7 �Yes ❑No Comments: <br /> Can BWU be pulled oul for inspection and mainlenance after loosening thumb screw? (�'1'es ❑ No <br /> Is BWD locked into the pro e osilion and thumb screw tlghtened? �Yes ❑No <br /> Circle the BWD cov . irrigaGon cover(I dscape area)I Vaffic load bearing cover(drive suria�e)I accass hatch(building) <br /> Was property owner shown the location of the installed BWD? �Yes ❑ No Comments: <br /> �Froperty,Owner`sSignature�—"`�.�� ` �—�� Date: /2 � <br /> Installer's Signature:� Date: <br /> Revision: 2 1 Friday,Septemher 12,2014 <br />