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� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Inio: %: 8 —� � Z <br />Date Backwater Prevention device (BWD) was installed: Date lhis form was completed: � 2 1 <br />Installation Property Owner Name and Conlact Info � VC�-L �dt«v` <br />Property Address: � �a �'2-��'t'1 � <br />Pre•Installatlon Inspection Checklist: <br />All dems must be checked 'Yes' in order Ior a BWD fo be considered (or insfalfation <br />Is ihere a basement or levei ot the house ihat is at or.�ear assumed sewer main elevalion? `— es ❑ No <br />Are there fixtures in the house located 6elow the upslream sewer manhole rim elevation? es ❑ No <br />Is the side se�.ver currenllv UNPROTECTED irom sewer backups (does not have a BVJD insfalied)? ��'e5 ❑ No <br />Site Inspection Checklist: <br />All items mus? be checked 'Yes' belore rnspecfion is conside2d complefe <br />Was side sewer TV inspected irom building to sewer main? [}i'es ❑ No Condiuon: O�C <br />Dces side sewer have at least 1°h slope from the building to sewer main? Q�'es ❑ Plo Qescribe: <br />Have all building sewer drain connections to the side sewer been identified and located? [{�es ❑ No <br />Have all property storm drai�age connections to the side sewer been iden6fied and locate�d? [L�1`es ❑ No <br />Has property been evalualed for drainage deficiencies wilh findings communicated to property owner? [�es ❑ No <br />Installation Details: <br />What type and brand of BYJD was installed at this sile (Clean Check B1h�V, Grinder <br />:Nhere v�as Ihe device inslalled (general description, attach map)? 1�S l c <br />Was there any other sewer or storm drainage �vork compieted in conjunclion wilh Ihe B'ND work? Is so please descnbe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnecled from upstream of the BWD1 es ❑ No Comments: �l� �'' <br />Does BWD positioning meets minimum slape requirement oi >1%? Q'i`�s ❑ No Comments: _ <br />Can BWD be pulled out tor inspection and maintenance afler loosening Ihumb screw? ❑ Yes � No <br />Is BWD tocked into ihe proper position and lhumb screw tightened? ❑ Yes ❑ No <br />� <br />Circle the BWD cover imgation cover (landscape area)1 traffi, load bezring cover (drive surface) f ccess hatch (bui;ding) <br />Was property ov,ner shown lhe location of ihe instalied BWD7 [e�'f� � No Comments: <br />Property Owner's Si Ure�� � � � Dale: ��`�2�1 �J <br />/�,� � Date T'7vai' L�-`�,� <br />Installer's Signatur : ( 1`tl`� <br />Hevision: 2 1 Friday, September ] 2, 2014 <br />