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'- - -� ' � . . ' i <br /> BACKWATER PREVENTIAN DEVICE FINAL <br /> INSTALLATION CHEC�(LIST <br /> Installafion Company Name and Contact Inio:� f; Q�`'`' `"^ Q � �9 <br /> Date Backwater Prevenlion device(BWD)was inshailed: /-2 G - f S _Dale this form�vas completed: 1- L� - �S <br /> Insle�lafion Property Owner Name and Contacl Info: AQ.R iC'}/cE�l K� _ <br /> � <br /> ProperfyAddress: /yQs G�AND /4 vr. Ev_5�en � � � 4g�� � <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD lo be consider�d fur insfallation <br /> Is ihere a basemenl or levei of the house that is at or near assumed sewer main elevation7[/�Yes ❑ No <br /> Are there fixtures in the house located below lhe upslream sewer manhole rim eleva6on?[[�es �� <br /> Is the side sewer curten8y UNPROTECTED irom sewer bac'�cups(does not have a BWD installed)?[�Yes ❑No <br /> Site Inspection Che�klist: <br /> All items must 6e checked'Yes'6e(ore inspec6on is considered complefe <br /> 1Nas side sewer N inspected from building to sewer main7 [�Yes ❑ No Condi6on: <br /> Does side se�ver have at least 1°o slope from lhe building to sewer main? [�Yes ❑No Describe: <br /> Have all 6uilding sewer drain connecfions to the side se�ver been iden6fietl and located? [(Yes ❑No <br /> Have all property stortn drainage connections to the side sewer been idenlified and located? [�Yes ❑ No <br /> Has property been evaluated tor drainage deficiencies tv'rth findings communicated to property ownef? �Yes ❑No <br /> Installation Details: <br /> What type and brand oi BWD was installed at this site lean Check B Grinder pump,etc.): <br /> Where was the device installed(gener�l descripfion,attach map)? l3 ���RD B rT,,.��e..e 4T+P/+�.� <br /> q n D }} 0 9 <br /> Was there any other setiver or storm drainage�vork completeci in conjunction with ihe BWD woriC?Is so please describe:,_ <br /> �c wtTt-�e 0 �4'rh $ _ e,ew-o�t0 o �.'t-o 5�,�wS►.r. (�Iot�cS <br /> InsWllation Checklist: �,/ <br /> Are all dovmspouts and site drainage disconnected from upsUeam of the BWD? L'1 Yes ❑No Comments: <br /> Does BWD positioning meets minlmum slope requirement of>1%? �Yes ❑No �C,o,�mments: <br /> Can BIh�D be pulled out for inspeclion and meintenance after loosenin�g,t(humb scret�/? L1 res ❑No <br /> Is BWD locked into the proper posilion and thumb screa�tightened? �J Yes ❑No <br /> Circle ihe BWD wver: irtigation cover(landscape area)I traffic load bearing cover(drive sur(ace)/access hatch(building) <br /> Was property owner sho�vn the localion of lhe inslalled B�ND? [�Yes ❑ No Comments: <br /> Property O�mers Signatu � Dale: /- �� '�'s _ <br /> Installer's Signature:� � � Date:fi'�v�-�',�'�J.�� _ <br /> Revision:2 1 Friday,Septembcr 12,2014 <br />