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�. <br />� <br />BACK'JVATER PREVENTION DEVICE FINAL <br />iNSTALLATION CHECKLIST <br />Instaliation Company Name and Contact Info:Jt�.L <br />Dale Backwa�er Prevention device (BWD} was insta <br />I�stallation Property Ovmer Name and Contact Info: <br />Properly Address: ��� 1"�c���� 4 <br />Cc.cn <br />5 <br />� <br />Date lhis form was <br />Pre-Installation Inspection Checklist: <br />Alf ilems must be checked 'Yes' in order for a BWD to 6e consideied for installation <br />Is there a basement or level of the house that is at or near assumed sewer main eievation? �'es ❑ No <br />Are there Tixturr,s in the house located below the upslream sewer manhole rim elevation? (�'es ❑ No <br />Is the side sewer currently UNPROTECTED (rom sewer backups (does not have a BWD ir.stalled)7 �!!es ❑ No <br />Site Inspection Checklist: <br />All items musf be checked 'Ves' before inspection is considered complete �- I <br />�h�as side sewer TV inspected from building to sewer main? �Yes ❑ No Condilion: I�cSC�ok <br />Does side sewer have at Ieast 1% siope from the building to se�ver main? �Yes ❑ No Describe: <br />Have all building sewer drain conneclions to the side sewer been identified and localed? [�Yes ❑ No <br />Have all property storm drainage connections to ihe side sewer been identified and located? [�es ❑ �o <br />Has property been evaluated for drainage deficiencies wilh findings communicated lo properly owner? �'es ❑ No <br />Installation Details: <br />1Nhat type and brand of BWD vras installed at this site (Clean Check BWV, Grinder pwnp, etc.): � � <br />Where was lhe device installed (general descriplion, aftach map)? i�–,�.� �2�rr^,�SQc� !�t-S gi �,i I't <br />Was there any other sewer or storm drainage +vork completed in con�unotion with the BWD �n�ork? Is so please describe: _ <br />Installation Che�klist: <br />N�e all do�vnspouts and site drainage discannected from upstream of the BWD? �'es [� No Comments: <br />Does BWD posilioning meets minimum slope requirement of>1%? [�1'es ❑ No Cor,iments: <br />Can BWD be puiled out for inspection and maintenance after loosening thumb screw? j��'es ❑ No <br />Is BWD locked into the proper osAiea-and thumb screw tigh(ened? [�>1'es ❑ No <br />Clrcle the 8WD cov . urigation coyer dscape area) / Vaffic load bearing cover (drive surface)1 access hatch (h�ilding) <br />Was property owner shown lhe loca�d of lhe-in alled BWD? �'es ❑ No Comments: <br />Property0wnersSignature: ��""" /r�'� Date: l%'�/K` �/" <br />Installer's Signature � Date: — '— ls <br />Revision: 2 ' � `� 1 Friday, September 12, 2014 <br />