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� <br />� <br />BACKWATER PREVEI�TION DEVICE FINAL <br />INSTALLATION CHECKLIc i <br />Cccrl <br />Installation Company Name and Contact Info:Jr�.!- <br />Dale Backwaler Prevention device (BWD) was insiz <br />�� <br />Date this form was completed: n� 11 �l�_ <br />Installation Property Owner Name and Contacl Info:,����.��—�"��� '��s�� "' <br />PropertyAddress: ,�(x_ ��_...e I�2�, 1/ � a�i �' ?P�4�� G�� <br />� <br />Pre-Installation Inspection Checklist: <br />All items must 6e checked 'Yes' in order 1or a BWD fo be considered for insiallafion <br />Is there a basement or level o( ihe house lhat is at or near assumed sewer main elevation? �Yes ❑ No <br />Are ihere fixtures in the house located belnw the upstream sewer manhole rim elevation? �Yes ❑ No <br />is ihe sid� seveer currently UNPROTECTED irom sewer backups (tloes not have a BWD installetl)? [�'es ❑ No <br />5ite Inspection Checklist: <br />�II ifems must be checked 'Yes' before inspection is considered complote � <br />Was side sewer TV inspected from building to sewer mai�7 �Yes ❑ No Condition: _�(� <br />Does side sewer have at least 1% slope trom ihe building to sewer main? [�Yes ❑ No Describe: <br />Have all building sewer drain conneclions to lhe side sewer been iden6fied and located? �les ❑ No <br />liave all property slorm drainage connections to the side sewer been identifed and located7 ��Yes ❑ No <br />Has property been evaluated for drainage deficiencies v�ith findings communicated to properly owner? � Yes ❑ No <br />Installation Details: �� -- � r. � <br />What iype and brand oi IiWD was inslalled at ihis site (Clean Check BWV, Grinder pump, elc.): _ -� <br />Where �vas ihe device inslalled (genem� description, altach map)? �,P __(���fl ��./_�._�� <br />Was there any other sewer or slorm drainage worle completed in conjunction wilh Ihe BWD workl Is so piease describe: _ <br />-----f_'l'.dYS.� <br />Installation CheeklisL• <br />rlre all downspouls and sile drainage disconnecled from upsUeam of ih� BWD? �'es ❑ No Commenls __ <br />Does BWD positioning meets minimum slope requirement ot>1"/o7 j�'es �� No Cammenls �.__ <br />Can BWD be pulled out (or inspeclion antl mainlenance afler loosening fhumb screw? �Yes ❑ No <br />Is �WD locked into the proper �osilion and Ihumb screw lighlened? � Yes ❑ No <br />Circle Ihe BWD wver rriyation cover ndscape a�ea) I Ira(fic load bearing cover (drive surtace)1 access hetch (building) <br />� <br />Was property o�vner shown Oie loca�ion oI llie inslalled BWD?� Yes ❑ No Comments: _ <br />N <br />Property Ovmer's SignaWre: � Date: ��� _l� <br />inslaller's Signature: _ _ _ �� Date: ��� __ <br />—�r-�—� <br />Revision: 2 ] Priday, Seplcmber 12, 2014 <br />