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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Inslaltation Company Name and Contacl Info: � <br />Date Back�valer Prevention device (BWD) was inslz <br />Insfallalion Property O�vner Name and Cantact Info: <br />Property Address: � 3�� C-U L ���1 <br />Pre•Installation Inspection Checklist: <br />t.[ � t � 1—�-t.ri i— v� c, a <br />Date this form was compieted: '"� �-�� <br />All items must be checked 'Yes'rn order fora BWD fo be considered for installafion <br />Is ihere a basement or level of Ihe house thal is at or near assumed sewer main elevafion7 es ❑ No <br />Are there fixtures in lhe house located below the upstream sewer manhole rim elevalion7 [�.1Ges ❑ No <br />Is 1he side sewer currentiy UNPROTECTED from sewer backups (does not have a BWD inslalled)? [(�a'es ❑ No <br />Site Inspection Checklist: <br />Ali items must be checked'Yes' be(ore inspection is considered complete <br />Was side sewerTV inspected from building to sewer main? [�f�s-� No Condilion: <br />Does side sewer have al least 1% slope irom the building to sewer main? [l�ftf ❑ No Describe: <br />Have all building sewer drain connections to ihe side sewer been identified and located? [+�}''Pes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? �a'es ❑ No <br />Has property been evaluatetl tor drainage deficiencies with findings communicated to property owner7 �'fes ❑ No <br />Installation Details: <br />What rype and brand of BWD e�as inslalletl at this sit (Clean Che�k BWV�� nder pump, etc.j: ^ G � E�G, ' <br />Where �vas the device installed (general description, attach map)7 <br />Was lhere any other sewer or storm drainage work completed in conjunction wilh the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and sile drainage disconnected from upstream of the Bl4�D? es ❑ No Commenls: <br />Does BWD positioning meels minimum slope requirementol>t%7 �� ❑ No Camments: <br />Can BWD be pulled out for inspeclion and mainlenance a(ter loosening lhumb screwl �fe�' [] No <br />Is BWD locked into Ihe proper posi6on an w lighlened? [�f¢5 ❑ No <br />Circle the BWD cover: irrigalion cove (landscape are Kc load bearing cover (drive suriace)! access hatch (huilding) <br />Was property owner shown the localion of lhe installed BWD7 [�Y� No Comments; <br />� <br />Property Owners Signa Date: 'Y x' �5' <br />Installer's Signalure: - ��� Date: �I • Z� �S� <br />Revision: 2 1 Friday, September 12, 2014 <br />