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� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact In(o: ���//;� r/H� �"� a'� n r s"fsi —�-= G"� <br />Date Ba�k�vater Preeention device (BWD) was installed: 2�I�'%� � Data this form was completed: ��/%r <br />Insta'lalion Property Owner Name and Conta�l Info: ��,c�� uti � h�' ��S� � 1��� <br />PropertyAddress: �'/7 G'�v �v •���' �✓�" /��� <br />Pre•Installation Inspection Checklisl: <br />All items must be checked'Yes' in order (ora BWD to be considered /orinstallation <br />Is ihere a basemenl or level oi lhe house ihat is at or near ass�med setiver main elevalion?� Yes [] No <br />A�e there fixtures in the house IocateJ be�c;� ;he upstream se�,ver manhaie rim elevation?� Yes ❑ No <br />Is the side se�ver currentiy UNPROTECTED (rom sewer backups (does not have a BNJD inslalled)? � Yes ❑ No <br />Site Inspection Checklist: / <br />All items must 6e checked 'Yes' be/are inspectron is considered complete <br />4Vas side sewer N inspected irom buiiding to se�ver main? �Yes ❑ No Condition: <br />Ooes side se�ver have a:least 1`/e slope from the building to se�:er main? �Yes ❑ No Describe: <br />Have all building seuer drein connections to the side sewer been identified and localed? ,� Yes ❑ No <br />Have all property slorm drainage conneclions to the side sewer been identified and located? ,[ res ❑ No <br />Has property been eva!�ated for drainage deficiencies �vith findings communicated to property owne��Yes ❑ No <br />Installation Details: <br />What type and brand o( BWD was instailed at ihis site (Clean Check BVJV, Grinder pump, etc.): r���a<, �n i3 i.✓ v <br />Where �:�as the device inslalled (general descriplion, attach map)? S w ��in�� 06 do�.sc=��� � <br />1h'as lhere any olher sewer or storm drainage �vor;c compleled in conjunction �vith ihe BWD work? Is so please describe _ <br />Installation Checklist: <br />Are all downspouts and site drainage diseonnecled irom upsUeam ol lhe B�ND7� Yes ❑ No Commenls' <br />Does BWD posilioning meels minimum siope requiremenl of >1°0? Yes LJ No Commenis: <br />Can BWD be pulled out for inspection and mainlenanr.e after loo ening lhumb scre�v? � ies ❑ No <br />Is BWD locked inlo the proper position and <br />Circle lhe BWO <br />Was properly o�.vner <br />Property O�.vner's Signature: <br />Installe%s <br />cover <br />scre�v tightene� %� Yes ❑ No <br />area I1Paffic load bearing cover (drive surface) I access halch (building) <br />ail BWD? �fes ❑ No Comments: <br />Date: �L3�/� <br />Dale: �3��r� <br />Revision: 2 1 Friday, September 12, 2014 <br />