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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ,g/uao. � <br /> Insiallation Company Name and Contacl Info: � <br /> Date Backwater Prevenlion device(BWD)was insiailed:l�-7'a- Dale ihis form was compleled: �- <br /> Installation Property Owner Name and Contact Info: �D�-� �S (N, <br /> Property Address: _al C�� C-1��-�� �f� �'4� �� � � �— <br /> Pre•Inslallation Inspection Checklist: , <br /> All items musl be checked'Yes'in order lor a BWD fo be considered for inslallation <br /> Is lhere a basement or level of the house lhal is at or near assumed sewer main elevalion? es ❑No <br /> Are there fixtures in lhe house lo�ated beiow the upstream sewer manhole rim elevation?�N�s �No <br /> Is the side se�.ver currenlly UNPROTECTED from sewer backups(does nol have a BUJD insfalled)? es ❑ No <br /> 5ite Inspection Checklist: <br /> All items musf be checked'Yes'before inspection is considered complete <br /> Was side sewer N inspected irom building to sewer main? ❑Yes 01�o Condition: ,.f.�-�.,�L�^-tr^-r' <br /> Does side sewer have at least 1%slope irom the building to sewer main? �Yes ❑No Describe: e vL� G/i�^�' <br /> Have all building sewer drain conneclions to lhe side sewer been ident�ed and located? n-Ygs ❑No � <br /> H3ve all property slortn drainage connections to Ihe side sewer been identified and localed? ❑Yes ❑No <br /> Has property been evalualed tor drainage defidencies with findings communicated lo property owner? ❑Yes � <br /> Installation Details: <br /> What type and brand o(BWD was inslalled at this site(Clean Check BWV,Grinder pump,elc.): <br /> i <br /> Where was the device installed (general descriplion,atlach map)? �v w���`� ,�S '� � <br /> �� <br /> Was there any olher se�ver or slortn drainage�vork completed in conjunclion wilh the BWD work?Is so please describe�_ <br /> Installation Checklist: <br /> Are all downspouls and site drainage disconnecled irom upslream of Ihe B�ND? es ❑No Commenls: <br /> �� <br /> Does BWD positioning meels minimum slope requirement o(>1%a? �l'es ❑No Commenls: ��- (�n r✓� ' <br /> Can BWD be pulled out tor inspeclion and mainlenance afler loosening ihumb screvr? [�es ❑No /l//�S • <br /> Is BWD locked into the proper posilion and thumb screw tightened? ❑Yes [L�� /1/ � S <br /> Circle the BWD cover: irrigation cover(landscape area)I Iraific load hearing cover(drive surface)I access halch building) <br /> Was properly owner shown lhe ation o(the installed 8WD? �res ❑No Comments: �'� f a " <br /> Properly Owner's Signa <br /> � / . r Date:���IduL� <br /> Installer's Signature -- Dale: /c����` �/�� <br /> Revision:2 1 Friday,September 12, 201A <br />