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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />—G <br />Date Backwater Prevenlion device (BWD) was inslalled: ��`Z"Z--vs Date this form was campleted: �- Zz-' j <br />Installation Property Owner Name and Contact Into: �'�L lN'e-��-� r��-�' <br />Property Address: � � � Z o\� �/�� <br />Pre�Insailation Inspection Checklist: <br />Alf 8ems must be checked 'Ves' in order for a BWD to be cronsidered for rnstallafion <br />Is there a basement or level of t� ie house that is at or near assumed sewer main elevaGon? es ❑ No <br />Are there fixNres in the house located below the upstream sewer manhote rim elevatlon? �s ❑ No <br />Is the side sewer currently UNPROTECTED from sewer hackup� (dces not have a BWO installed)7 [�Yes ❑ No <br />Site Inlpection Checklist: <br />All dems must 6e checked 'Yes' 6efore inspecfion is cnnsidered complete � ��. <br />Was side sewer TV inspected from building to sewer main? [�'YEs ❑ No Condition: _{,�� �-� I onGtr�' - <br />Dces side sewer have at least 1% slope from the building to sewer main? �i'�s ❑ No Descnbe: <br />Nave all huilding sewer dr2in cannectlons to the side sewer been identified and located7 �N�s ❑ No <br />Have all propeAy storm drainage conr�ec6ons lo the side sewer been idenlfied and located? es ❑ No <br />Has praperty been evalualed for drainage deficiencies with findings communicated lo property owne�? [�Y€s ❑ No <br />Installnion Details: ��C <br />Whal type and brand ot BWD was installed at this site (Ciean Check BWV, Grinder pump, etc.): ,�._. <br />Where was the device invlalled (general description, attach map)7 �'�e �'�'� � — <br />Was there any other sewer or storm drainage woric compieted i�,con��'u`nQction wilh the BWD work? Is so please describe: <br />�fJ ' <br />Installation Chacklist: <br />Are all downspouts and sile drainage disconneoled from upsheam o( the BWD? [�}�s ❑ No Commenis: <br />Dces BWD posilioning m�ets minimum siope requirement of >i°/a7 �s ❑ No Comments: <br />Can BWD he pulled ou! lor inspec6on and maintenance after loosenin9 Ihumb screw? �s ❑ No <br />Is BWD locked into the proper position and thumb screw tightened7 [y'�es U No <br />Circle the BWD cover. irrigation co r(landscape area�ffic load bearing cover (drive surtace) / access hatch (building) <br />Was property owner shown the location ol the installed BWD7 ��s ❑ No Camments: <br />Property Owner's Signature: � Date: !a - Z'�- ` S <br />Instaiiers Signatore: � Date: Cv ' �-�_ `ti— <br />Revision: 2 1 Friday, September 12, 2014 <br />