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BACKWATER PREVENTION DEVICE FfNAL <br />fiVSTALLATtOIV CHECKLIST <br />�r1C;�ri Gcci'1 ��/� � �^}- `;, � SC�L7J'� L LG <br />Installalion Company Name 2nd Contast Info:.�} <br />Date Backmater Prevention device (BWD) was inste <br />Installation Property Owner Name and Contact In(o: <br />Property Address: 7 ��� ��YY� �� <br />Date this torm was completed: `�1�[tij— <br />vo /1-�:r-_ ��7n�!„>>G <br />Pre•Installation Inspection Checklist: <br />All items must ba checked 'Ves' in order Ior a QWD 10 be considered for insiallation <br />Is there a basement or level of ihe house ihal is at or near assumed sewer main elevation? [�iYes ❑ No <br />Are there f:xtures in the house located belova the upsiream se�ver manhote rim elevation? �Yes ❑ No <br />'s the side sewer currently UNPROTECTED irom sewer backups (tloes not have a BWD insfalled)? [�Xes ❑ No <br />Site !nspection Checklist: <br />All ite.�is must be checked 'Yes' before rnspection is considered complete - I <br />Was sine sev;er TV inspectetl from building to seeaer m2in? (�Yes ❑ No Condition: �,1`X:1 <br />Does side sewer have at least 1�/o slope from the building to sewer main? � Yes ❑ No Describe: . <br />Have ail building se�ver drain connections to Ihe sitle sev�er been identitied and located? �es ❑ No <br />Flave all property storm drainage connecUons ro t'ie side se�ver been identified and localed7 �Yes ❑ No <br />Has property been evaluated for drainage deticiencies with findings communicated to property owner? (�Yes ❑ No <br />Installation Details: <br />lNhat type and brand oi BWD was installed al this site (Clean Check BWV, Grinder pump, etc.): c` � <br />INhere a�as the device installed (general descripiion, atlar.h map)? �?�' (]'� ���v1-�1—��C j�Jd._L] <br />lNas there any otner sevaer or storm drainage �vork completed in conjunction wilh the B14�D work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouls and site drainage disconnected from upslream of ihe f3WD? �'1'es ❑ No Commenls: <br />Does BWD positioning mee(s minimum slope requiremenl of >1 °Io2 �'Yes ❑ No Comments: <br />Can BIND be pulled oul for inspeclion and main(enance alter loosening ihumb screw? j�Yes ❑ No <br />Is BWD locked inla Ihe proper posilion and thumb screw lightened? �'es ❑ Na <br />Clrcie the BWD cover: ngation cover I ntlscape area) ! traffic Ioatl bearing cover (drive surtace) ! aceess hatch (builtling) <br />Was property owner s <br />Properly Owner's <br />Installers Signature: <br />of the insfalled 9YVD? �Yes <br />n <br />❑ No Camments: <br />Dale: - ` — " � ` �• � <br />Date: y " ��� '� ( -7 <br />Revision: 2' % 1 Friday, September 12, 201A <br />