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� <br /> BACKWATER PREVENTION DEVICE FINAL <br /> {NSTALLATION CHECKLIST � <br /> � <br /> ; <br /> I <br /> Installation Company Dlame and Contact Infi: l�:C,� ����,�,�,,�„� �(�S 7L t� �3C o j <br /> I <br /> Date Backwater Prevenlian dewce(BWD)was installed: �3-3'�S ?ate this torm was completed: ?-I'y-I S- � <br /> Installation Property Owner Name and Contact Info: �ti��� 'rrP, �c,� N� S - 3v:��- I r U6 � <br /> PropertyAddress: '�` I D il Nt,y � /'�--c r,�.�-�%}l �-l� S.Y��=� ! <br /> � <br /> Pre-Installation Inspection Checklist: � <br /> Af!ifems must be checked'Yes'in order lor a BWD to be consrdered forinstolfation � <br /> Is there a basement or levei o(the house that is at or near assumed sevecr main elevation?Q Yes ❑No <br /> Are there fixtures in the house located below ihe upstream sewer menhole rim elevation?�Yes ❑ No <br /> Is ihe side sewer currently UNPROTECTED from sewer 6ackups (does rot have a BWD installed)?�Yes ❑No � <br /> Slte Inspection Checklist: <br /> �lo �`(2¢c�nc�le. c,cc�s� •fu <br /> Aflkemsmustbechecked'Yes'beforeinspectionisconsideredcomplete ��.��y� iN#�zc�} c���' �r"`�-• <br /> Was side setver N inspected from buiWing to sewer main? ❑Yes ❑�o Condition: ' <br /> Dces side sewer have at least 1%slope from the building to sewer main? ❑Yes ❑ A'o Describe: ; <br /> Have a!I building sewer drain ccnneclions to the side sewer bean identified and located? Q Yes ❑No ; <br /> Have all p�operty storm drainage connec6ons to the side sewer been identified and located? �Yes ❑No <br /> Has property been evaluafed fordrainage deficiencies with findings cemmunicated to propeRy ownerl �Yes ❑ No � <br /> Installation Details: � <br /> i <br /> What type and brand�f BWD was installed at this site(Clean Check[3WV,Grinder pump,etc.): �Unn(c i ! <br /> Where was the device installed(general descrip6on,attach map)? (L'� n�" �l�u S'.��h ��� �;cr-�.h- ; <br /> , <br /> � <br /> 4 <br /> Was there any other sevrer or stortn drainago work compieled in conjunction vn�h the BWD work7 Is so please describe:� j <br /> Instaliation Checklist: j <br /> Are ali dovmsp�uts and site drainage disconnected from upstream of the BWD? (�Yes ❑No Comments: � <br /> I <br /> Does BWD positioning meets minimum siope requirement of>1%? �Yes ❑ No Comments: i <br /> Can BWD be pulied out for inspection and maintenance a(ler loosening thumb screW?..�]�'es-e-No— � <br /> Is BWO Iocked in�o the proper position and thumb screw tightened? j]Y.es-B-Na—� <br /> Circle the BWD cover. irrigaGon cover Qandscape area)1 traffic load bearing cover(dnve surface) accrec hatrh f'h�i�ding) ! <br /> Was ro e owner shown Ihe loca6on of ihe instailed BWD? � <br /> p p rty (�]Yes ❑No Comments: <br /> f <br /> Property Ovmer s Signature: Date: � <br /> Installers Signature: ..�J ���----- Date: � <br /> i <br /> Revisic�i:2 1 Monday,September 15,2014 i <br /> r <br /> � <br />