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//�/�y <br />,� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Conlact Info: �\O �'� <br />Date Back�vater Prevention device (BWD) was Installed:_ (O' c' I s Date this form was cornpleted: (o' l2- �S <br />Installation Properiy Ovaner Name and Contact Info: �lav� T �� �k.� — <br />Property Address: 3S I a C�+� A�� <br />Pre•lnstallation Inspection Checklist: <br />All items must 6e checked'Yes' in order for a BWD to be considered lor fnstallation <br />Is there a basemenf or level of the house that is al or near assumed sewer main elevation? � Yes ❑ No <br />Hre there fxtures in the house loated belovd the upstream sewer manhole rim elevallon? � Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sevrer backups (does not have a BWD irstalled)7 (� Yes ❑ No <br />Site Inspection Checklist: <br />All ifems must be checked'Ves' before inspection is considered complete <br />Was side sewer N inspected ftom buiiding to sev�er main? j�] Yes ❑ No Condition: <br />Does side setiver have at least 1% slope from the building lo sewer main? �] Yes ❑ No Describe: <br />Have all building sevaerdrain connections 'o the side �ewer 6een Idenfified and located? � Yes ❑ No <br />Have all property storm drainage connections to 1he side sewer been identitied and located? � Yes ❑ No <br />Has propedy been evalualetl for drainage deficiencies v�ilh fndings com�rounicated to property o�vner? ��Yes ❑ No <br />Installation Details: <br />What iype and brand of BWD was installed al ihis sit Clean Check B, Grinder pump, etc.): <br />Where �ti�as Ihe device installed (general description, altac map)? /i� c,l� �' �.n a� h.,�%� ��ti F -- <br />..✓ �(nc�OwS <br />VJas lhere any other sewer or storm drainage e+ork compleled in conjunction wifh the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouls and site drainage disconnected irom upstream of the BWD? �Yes ❑ No Comments: <br />Does BVJD positioning meets minimum slope requirement of >1%? ,[�] Yes ❑ No Comments: <br />Can BWD be pulled out for (nspecllon and maintenance after Ioosening lhumb scre�v?�] Yes ❑ No <br />Is BWD locked into the proper osiUomaitd-U b screw lighlened? � Yes L.J No <br />Circle the BWD cove . irrigation crover (landscape area 1 raftc load bearing cover (drive surface) I access hatch (6uilding) <br />Was property owner shovm th�e I�tion o t e inslalled BWD? [/�Yes ❑ No Comr,ients: <br />Property Owner's 5ignat�re: _ Date: <br />Instailers Signature: _ �— -- Date: � - �z – �r <br />� ''�' 2014 <br />Revision: 2 1 Fnday, September 12, <br />