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BACKWATER PREVENTION DEVICE FINAl. <br />BNST'ALLATiON CHECKLIST <br />Installation Company Name and Contact Info: � <br />Dale �ackv�aler Prevention device (BWD) was insta <br />Instaflation Property Owner Name and Confact Info: <br />Property Address: � l \ Ul-L? <br />���2,c- y8 g- o � z� <br />Date lhis form was completed: ' � "�� <br />�.lLe 'I 1C� ^ C���i l <br />Pre•Installation I��spection Checklist: <br />All ifems mi�st 6e checked 'Yes' rn order tor a BWD to be considered for insfaliation <br />Is there a basemenl or level of Ihe house that is at or near assumed sewer main elevation7 [�5�es ❑ No <br />Are lhere fixtures in fhe house localed below Ihe upslream sewer manhole rim elevation7 (�Es ❑ No <br />Is lhe side sewer currently UNPROTECTED from sev,er backups (does not have a BWD inslalledj? ��s ❑ No <br />Site Inspection Checkiist; <br />AII rfems musf 6e checked'Yes' belore inspectron is considered rnmpfete � S` o� � <br />Was side sewer TV inspected from building to sewer main? [�fes ❑ No Condition: Z_1,� M� <br />Dces side sewer have al least 1% slope irom t he bui l ding to sewer main? es ❑ No Describe: L� �b <br />Have all building sewer drain connections to the sitle sewer been identified and located? ►[�'Bs ❑ No <br />Have all property storm drainage connections to the side sewer been idenlified and locatetl? [��Y� ❑ No <br />Has properly been evaluated tor drainage deficiencies wilh findings communicated to property owner? 0'rs ❑ No <br />Installation DeWils: � <br />Whal type and brand of BWD was inslalled at this sile (Clean Check BWV, Grinder pump, etc.): � ���-�-��-- ^ <br />Where was lhe device inslalled (general descriplion, attach map)? ��� �� ��+-�-� <br />Was lhere any other sewer or storm drainage vrork completed in conjunclion wilh the BWD work? Is so please descnbe: _ <br />� �,V`-C- ^ <br />Installation Checklist: �,,� <br />Are ail downspouls and sile drainage disconnected from upslream of Ihe BWD� Uv res ❑ Ido Commenls: �� � <br />Does BWD posilioning meets minimcr•; slope requirement of >1%9 [�.]�s ❑ No CommeNs: 2- -1 0 <br />Can BWD be pulled oul for inspectio�� and mainlenance af(er loosening Ihumb screw? es ❑ No <br />Is BWD tocked into Ihe proper position rew lighlened7 �� ❑ No <br />Circle Ihe BWD cover: imgation co ndsca e are Ira(fic load bearing cover (drive surface) I access halch (building) <br />Was property ownsr shown Ihe location of Ihe inslalled DWD? �y�s LJ No <br />Property0�vnersSignatur �'. <br />Installer's Signalure: <br />Commenls: <br />Date: �� l �--1 `J <br />Date: �' �� � �5� <br />Revision: ] 1 Friday, Septemher 12, 2014 <br />