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� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATIAN CHECKLIST <br />Ccxn ��,pt�� c� <br />Installation Company Name and Conlact Into:J� '!-i" KiCC� (�#�'��'►'�-�l�l•5�// [��� c.:1tw2��t��nfC1;.4;, <br />Date Backwaler Prevention device (BWD) was installed:��(,y Date this form was compleied:��,1 _ <br />Inslallalion Properly Owner Name and Conlacl Info: 1�1,1.�=. _�q �. Q . �-�- �a �— ��— _,[[.� <br />Properly Address � 1(Jto l.Q�1,10U�� 7i -� lY=� )'ed1�.�! <br />Prc•Ins!allation Inspection Checklist: <br />All items must be checked'Yes' in order for a B WD lo be considered for insfallation <br />Is ihere a basement or level of lhe house ihat is at or near assumed sewer main elPvalion�es ❑ No <br />Are tliere fixtu�s in the house localed below Ihe upsiream sew�� manhole rim eievalioa� Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (tloes not have a BWD installed)?�Yes ❑ No <br />5ite Inspection Checklist• <br />All ifems must be checked'Yes' be%re inspection is considered complete � � <br />UJas side sewer TV inspecled from building lo se�ver main? �'Yos ❑ No Condition: �orf�Yl _ <br />Does side sewer have at least 1°b siope trom the building to sewer main? [�'es ❑ No Describe: <br />Have all building sewer drain conneclions to the side sevrer been identified and located? [�-Yes ❑ No <br />Have all property storm drainage evnneclions to the side sewer been idenlified and located? �Yes ❑ No <br />Has properiy been evaluated for drainage deficiencies with findings communicafed lo properly owner? {�Yos ❑ No <br />Installaiion Details: <br />What type and brand o( BWD �vas instailed af this site (Clean Check BWV, Grinder pump, etc.): _ �� <br />�Nhere was ihe devir.e installed (general description, atlar.h map)? �P Q�/.�Gf�-[��-( f�-S _(/`�L(,cL"� <br />Was ihere any other sewer or slorm draina,ye work compleled in conjuncti�n with lhr. BWD work? Is so please describe: <br />Installation ChecklisL <br />Are all downspouts and site dmina�e disconnec�ed Bnm upsiream o( the BWD? �fes ❑ No Commenls: <br />Does �WD posilioning meels minimum slope requirement ot>1%7 (�'es ❑ iVo Commenis: __ __ <br />Can BWD be pulled oul tor insper.lion and maintenance afler loosening Ihumb screv�7 �Yes ❑ No <br />Is f3W0 looked into thr. prcper posilion and thumb serew lighlcned? (�Nes ❑ No <br />Cirde lhe BWD cov . irriyalion cyyr.r-(I scape area) I Iraflic loatl beanng cover (drive surface) ! access halch (building) <br />Was property owner shown Ihe location of the inslalled BWD'? (�Yes ❑ No Commenls: <br />r <br />Proporty Owner's Signature: _ _ � Dale: � � �� <br />Date:_� � � <br />Inslaller's Signatur __ _ __ � <br />Rr.vition: 2 <br />Frfday, September 12, 2014 <br />