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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: G ����+tii n � a S -7� O- U <br /> Date Backwater Prevention device(BWO)was installed: �/�P Da;e this form v�as completed: %��'�`� <br /> Installation Property Ovmer Name and Contact Info: /�'I �� i a,�-� Cc,t�'�2 ��a s-ya a - ��k� <br /> Properry Address: f�� O I uR.n� ,(Fv� G �u��f U A <br /> Pre-Installation Inspectlon Checklist: <br /> All items must be checked'Yes'in order for a BWD to be conside�ed for installation <br /> Is there a basement or level o(the house that is at or near assumed sewer main elavationl�Yes ❑No <br /> Are there fixlures in the house located below the upstream sewer manhole rim elevation?�Yes �No <br /> Is the side sewer currenNy UNPROTECTED irom sewer backups (does not I�ave a B1ND installed)?�Yes ❑No <br /> Site Inspectlon Checklist: <br /> All items must be checked'Yes'before inspection is considered complete ` <br /> lNas side sewer N inspected from building to sewer main? �Yes ❑ No Condition: h�L Or6�- �� ��'� <br /> Does side sewer have at least 1%slope from the building to sewer main? �Yes ❑No Describe: <br /> Have all building sewer drain connections to ihe side sewer been identified and located? �Yes ❑No <br /> Have all property slorm drainage connections to the side sewer been identi(ied and localed? �Yes ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? �Yes ❑No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,elc.): /1/�� <br /> Where was Ihe device installed(general description,ariach map)? �//A <br /> Was there any olher setver or slorm drainage work compleled in conjunction wilh lhe BWD�vork? Is so please describe:_ <br /> �/�� <br /> Installation Checklist: <br /> Are aIl downspouts and site drainage disconner,ted from upstream o(lhe BWD? �Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope reyuirement of>t%? ❑Yes ❑No Comments: N�f} <br /> Can BWD be pulled out for inspection and maintenance afler loosening thumb screw7 ❑Yes ❑No <br /> Is 8WD locked into the proper position and ihumb screw tightened? ❑Yes ❑No <br /> Circle the BWD cover: irrigation cover(landscape area)!t2ffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown Ihe lo;,ation of the installed BWD? ❑Yes ❑No Comments: <br /> Property Owners Signalure� Date: <br /> Installer's Signature: �Q � �'z�� Dale: q-e2 7' a v�_ <br /> Revision: 2 1 Monday,September 15,2014 <br />