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BACKWATER PREVENTION DEVICE FINAL <br /> � <br /> INSTALLATION CHECKLIST <br /> installation Company Name and Contact Info: ` � — S �' O�Z� <br /> Date Backwater Prevention device(BWD)was instalted: -��T S ate this form was completed: — �-� S� <br /> Installation Property Owner Name and Contact info: �/�✓�� �it1ZX� <br /> Property Address: ��2 �V�1— +i�� <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD to 6e considered(or installation <br /> Is there a basement or level o(lhe nouse thaf is al or near assumed sewer main elevafion? es ❑ No <br /> Are there fixtures in lhe house located below the upstream sewer manhole rim elevation? es ❑ No <br /> Is the side sewer currenlly UNPROTECTED (rom sewer backups (does not have a BWD instailed)?[/�N�s ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspecfion is consrdered complete /� � <br /> Was�ide sewer TV inspected from buildinc,to sewer main? ��s ❑No Condilion: /�l���� � T <br /> Does side sewer have at least 1% slope(rom Ihe building to sewer main? l[�-Y� ❑No Describe: <br /> Have ali building sev�er drain connections to the side sewer been identified and located? [�-1`es ❑ No <br /> Have all property storm drainage connec6ons to the side se�ver been identified and located7 [��'.es [}No <br /> Has property been evaluated fordrainagr;deficiencies with fndings communicaled to property owner? [}l�es ❑ No <br /> Installation Details: <br /> Whal type an ! brand of BWD was installed at this site (Clean Check BWV, Grinder pump,etc.): Gu-Pi�--�GC <br /> Where was lhe device instaile� (general description, attach map)? "� /'�-�f`1-� . <br /> � <br /> Was there any olher sewer or slor��inage w�k completecd�in- conjunction with the�1LUD work7 Is so please describa:_ <br /> -aJft— /L-�-�-/� �/�c.A <br /> , <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnecled from upstream o(the BWD? [L�'�s ❑No Comments: <br /> Does BWD positioning meels minimum slope requirement oi>1%7 [�Xe� ❑ No Commenis: <br /> Can BWD be pulied out for inspection and maintenance a(ler loosening ihumb screw? [�--}'fes ❑No <br /> Is BWD Iocked into ihe proper posilion and thumb screw tightened? [l�-1'es ❑No <br /> Circle the BWD cover: irrigation co�a r(landscape area ic load bearing cover(drive surface)!access hatch (building) <br /> Was properiy owner shown fhe lor;ation of ihe installed BWD7 es ❑No Commenls: <br /> � <br /> Properiy Owner's Signalure: ,�,5� u,./� �1 '/U Date: ��� � � <br /> Installer's Signature�l'� Date: �� <br /> Revision: 2 1 friday,September 12, 2014 <br />