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i • <br /> , • � � <br /> BACKWATER P'REVENTION DEVICE FIN�►L <br /> � INSTALLATION CHECKLIST <br /> � � � <br /> , <br /> � <br /> ; <br /> Inslallalinn Company Name and Comact In(o: �.�r�� r/' �,_1.i!'���,���S 1 1�.� ���( , <br /> � � --r— <br /> Oale Backivater Prevention device(BWD)was installed: S / 2v/5 Dale this form was completed: �/�1 z.�/�r <br /> '—_'-_'—�_— _ r <br /> (Installation�P.roperty O�vner Neme and Contact ln(o`; f r.� YU' �'�'i W"1 T 0 - yyq-3�G S <br /> � _ _ I _ _ �-.�;�_ �gzo1 <br /> �Property'Addre'ss: � � �v b V� CVC'('P� 11- <br /> i-- — <br /> Pre•Installation Insper.tion Checklist: � � <br /> All rfems musf be checked'Yes'in order for a BWD to De considered fo�instaAation <br /> Is there a basement or level ot the house that is a;or near assumed secver main elevation� Yes ❑No <br /> Are Ihere fzt�res in the house located belo�ti�th,e upslream sewer manhole rim eirvation? Yes ❑N <br /> Is Ihe side sevrer currently UNPROTECTED Irom sewer backups(does�nol have a [iWD installed)? Yes ❑ t�'o <br /> Sitc Inspection Checkiist: , <br /> All ilems must be checked 'Yes'betore rnspecfion is considered ccynpie'e <br /> N�as side sewer N inspectetl irom building to sewer main? j'j Yes ❑No ndition: <br /> Does side sev�er have at least 1%slope from the 6uilding to sewer main? Yes ❑ No scri6e:_ <br /> Have ail buitding sewerdrain connections to the side sewer been identi�ed and located? �s No <br /> Have all property storm drainage connections to the sitle sewer been idenlified and located? Yes ❑No; <br /> Has property been evalua(ed for drainage deficiencies wilh findings conimunicated lo property owner? �s ❑No <br /> Installation Details: I <br /> What type and brand of 8WD ti�as inslalled at this sile(Clean Check BVI,N, Grinder pump, ete.); C��n c�<< <br /> Wnere was ihe device installed(general description,allach map)? �c.c.le ya�.� — we s-F- s�d.e o� �.ou s� <br /> Was Ihere any other sewer or siorm drainage work compleled in conjunction wilh the OIND work? Is so please describe: ,►Jo <br /> i <br /> histallation Checkiist: <br /> Ari�all downspouls and sile drainaye disconnected(rom upslream of lhc;6WD? � Yes <br /> � ❑ No Commenls: <br /> Docs 81h�D posiliuniny meels minimum slope requiremenl of�1%? (�es ❑ No Co enis: <br /> Can 4WD be pulled out for inspection and!nairilenance a(ter loosening t�wmb screw? Yes ❑ No <br /> Is BWD I��cked info the pro er position and ihumh screw tighlened? �Yes ❑ No <br /> �Er.✓�R �v�R � <br /> Circle the BWD cover: irr�aHerrc.�ver andscape area)/Iraffic load be ring cover(tlnve suAace)/access halch (building) <br /> Was property o�vner shown the location of lho i�nslalled BWD? ' Yes i�No Commenis: <br /> � <br /> P,ro�i�rty0l��nr.�s'Si�nafure: �7 i rt� � I �5 <br /> Installer's Signalure:—���1-"�=->_ - � .,S / Ze� ( � <br /> � Date: <br /> Revision: 2 1 ! hlonday, Septr.mber 15, 2014 <br />