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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />, <br />'v`�F� �FC;r�� <br />Installa6on Company Name and Co�tact Info:,A(Yj��'1 .�2C' _�'1_�. - c�" •� '!� uC-: 'IC�"•' c c?-� '; <br />Date Backwater Preveniion device (3WD) was installed:,�,� I 1 Z� I Q' Date this form was oompleted: <br />Installation Property Owner Name� and Contacl Info: ��,��N%tO1,� Ca �(� <br />Property Address: <br />Pre-Installation InspeeGon Checklist: <br />All ifems must be checked 'Yes' in order fu; a BWD 10 be considered lor installafion <br />Is there a basement or Ievei of the house tnat is at or near assumed sewer main elevation? �Yes ❑ No <br />Are ihere fixtures in the house located below the upstream sewer manhole rim elevation? (�,Yes ❑ No <br />Is the side sewer currenUy UNPROTECTED from sewer backups (does not have a BWO instailed)7 �Yes ❑ No <br />Site Inspection Checkiist: <br />AI! items must be checked 'Ves' before inspection is considered complete , <br />Was side sewer N inspected from building to sewer main? � Yes ❑ No Condition: � <br />Coes side sewer have at least 1�o slope from the build'mg to sewer main? � Yes ❑ No Describe: _ <br />Have au building sewer drain connections to fhe side sewer been idenfrfied and locatedl � Yes ❑ No <br />Nave ali property storm drainage connections to the side sewer been identified and located7 (gYes ❑ No <br />Has property bee„ evaluated far drainage deficiencies with findings communirated to property owner? [�Yes ❑ No <br />Ir�stallation Details: <br />What rype and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): ' `° <br />Where was the device installed (general descripfion, attach map)? �� n�lJ�,�.� �S ,�.r(� <br />Was ihere any other sewer or storm drainage work complete,�1 in conjunchon with lhe BWD wwk? Is so please describe: _ <br />Inatallation Checklist: <br />Are all downspouts and site drainage disconnected (rom upstream of the BWD? [�Yes ❑ No Comments: <br />Does BWD positioning meets minimum sbpe requirement of >1%7 � Yes ❑ No Comments: <br />Can 9WD be pulled out for (nspecfion and ma'ilenance after loosening lhumb screw? � Yes ❑ No <br />Is BWD locked inlo Ihe nro�er-�e "on and thumt screw tightened? � Yes ❑ tJo <br />Circle the BWD cove : irrigafion cover landscape area)/ traffic load bearing cover (drive surtace)1 access hatch (building) <br />Was property owner shown the o ation of the installed BWD? � Yes ❑ No Comments: <br />Property Owner's Signature: ���fr✓l�--a�'�/� � Date: �' ��� <br />Installer's Signature: � Date� � � / <br />Revision: 2 1 Friday, September 12, 2014 <br />