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BACKWATER PREVENTION DEVICE FINAI� <br />INSTALLATION CHECKLIST <br />Inslallation Company Name and Contact Infb:. <br />Date Backwater Prevention device (BWD) was <br />this iortn was completed: Co— 2"z� !� <br />Instaliation Property Owner Name and Contact info: �""b.�- 1��,(.-� �w��-c� __ <br />Property Address: � v � "�o��`-� �'� <br />P�Install�tfon M6pe�.iion Checklist: <br />All items must be checked 'Yes' in ortier for a 8WD to be considered f�r insteilation <br />Is Ihere a basemeni or Ievel of ihe house that is al or near assumed sewer main elevation? es ❑ No <br />Are Ihere fixtures in the house located below the upstr�eam sewer manhole rim elevadon? [►�"�s ❑ No <br />Is Ihe side sewer currently UNPROTECTED imm sewer backups (does not have a BWD installed)9 QYes ❑ No <br />Site Inspecfion Checklist: � <br />All items must 6e checked 'Yes' befor� insp�ction is considered complete ��. <br />Was side sewer TV inspected from building to sewer main? [�s ❑ No CondiGon: [7Q s.. � I!_MG� - <br />Dces side sewer have at least 1`Yo slope 1rom lhe building lo sewer mainl [+�'fc�s ❑ No Cescnbe: <br />Have all building sewer drain eannections to the side sewer been identiBed arnl located? [�f�s ❑ No <br />Have all property slartn drainage connections tu Me side sewer been idenlified and located7 es ❑ No <br />Has praperty been evaluated (or drainage de�iciencies with findings commuNcated lo property owne�? [+�1'irs ❑ No <br />Inetallation Det�fis: r1 <br />What type and brand of 8WD was instatled at fhis site (Ciean Check BWV, Grinder pump, elc.): ��u-�'�'-n-�� • <br />Where was the device installed (general descriplion, attach map)? _ �e� �"+^�4P � <br />Was fhere any ofher sewer otstortn drainage work completed i wnjunclion with the BWU work9 Is so please descnbe: ,,,_, <br />�I,hA� � <br />installation Cheoklist: <br />Are all downspouts and site drainage disconnected from upsUeam of the BW07 �'P'es ❑ No Commenls: <br />Does BWD posilioning meets minimum s�ope requirement of >1�? Q�s ❑ Na Comments: _, <br />�an BWD be pulled oul far inspecfion and mainfenance after loosening Ihumb screw? [�'lres ❑ No <br />Is BWU locked into the N �'wr position and thumb screw fightened7 �s ❑ No <br />Circle the BW.0 cover, irrigation ca r(landscape area ffic load 4earing cover (drive sudace)1 access hatch (building) <br />Was property owner shown ihe Iocallon of Ihe inslalled BWD7 �❑ No Comments: <br />Prt,;�edy Owner's Sig�ature: �� � Uate: le -'Z�- `S <br />Insta�ler's Slgnature: 1(N" Date: �"'Z�= ° t� <br />Revision: 2 <br />Friday, September 12, 2014 <br />