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� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHf�CKLIST <br />1'Yl�fii <br />G "1' <br />Instaltation Company Nameand Comacl Info:..1r� ��.1• K; (� .,2`i,)-�`!4-��f_5��1( :��,� :w,)'��n- .�ro � <br />Date Badcwafer Prevention device (BWD) v+as inslalled:��,_ Date Ihis fonn �tes comple;ed:� <br />installalion Property O�vner Name and Contact Info: ��l_�'j_� ��'lY� �l Z�� -'��� �—�� -9_ <br />Property Address: <br />Prc-Installatio�i Inspeclion ChEcklist: <br />All items must be checked 'Yes' in order for a BWD to 6e cons:dered for install2tron <br />Is ihere a basement or level of it,e housa that is at or near assumed sewer main elevation? [�fes ❑ I�fo <br />Are there fixtures in the house loca�ed beloe� the upsheam sewer manhole rim elevation? �Yes ❑ No <br />Is the side sea�er currently UNPROTECTED irom se�ver backups {dnes nol have a BWD insialled)? (�Yes ❑ No <br />Site Inspe�tion Checklist: <br />/{lf r�ems must be checked'Yes' before inspection is considered complete � I <br />Was side sev+er N inspecled irom 6uilding lo sewer main? �'Yes ❑ No CondiUon: C019'�1.� <br />Does side se�ver have ai lea�t i`Yo slope froR� lhe building b sewer main? � Yes ❑ No Describe: _ <br />Have all buildirg sewer drain conneclions lo the side see+er been identitied and located? [�'es ❑ tJo <br />Have all property storm drainage ccnnections to the side se�ver been idenlifietl and located? ��'es ❑ No <br />Has property been evaluated for drainage defciencies vriih findings communicated to properly ovaner? � Yes ❑ No <br />Installation Uetails: /) <br />�Vhat type and brand of BWD tivas installed at Ihis site (Clean Check BWV, Grinder pump, etc.); �� �� �'� <br />4Vhere �v3s the device instailed (general descrip(ion, atlach map)? ..�, #'�� L'�„�� � c� � s,� . � <br />Was tt��re any other sevrer or stonn drainage work ompleted in conjunction �vith Qie E3WD work? Is so please describe: <br />��:�____- <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream oi the BWD? �'Yes ❑ No Commenls: <br />Does BtiVD positioning meels minimum slope requirement ol >t%? �'Yes ❑ No Commenis: <br />Can BWD be pulled out for inspection and maintenance af�er loosening thumb screw? �Yes ❑ No <br />Is BWD locked into the proper position and thumb screw lightened? �Yes ❑ Na <br />Circle the DWD co� e( Y irrigaGon cover Qa dscape area) / trafiic loatl bearing cover (drive surface) I access hatr,h (huilding) <br />�Vas properiy owner shown the localion of lhe installed BWD? �'es ❑ No Commenls: <br />Property Owncr's Signature: vZ'� � c�''�'� Date: �� zJ -�S <br />Inslaller's Signature: �~ � �� Date: � Z5 � <br />Reviiion: 2 1 Friday, Septem6er 12, 2014 <br />