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� <br />BACKWATER PREVENTION QE1/ICE FINAL <br />INSTALLATIQ�V CFIECKLIST <br />i�"1E'(`i Cc�n �x-;p� <br />Installation Company Name and Contact <br />�LL <br />Date Sack�vaier Prevention device (BWD) �,vas ii �stalled.�.�.�,�__ Date ;his form ;vas completed:��,� J <br />Instailation Property O�vner Neme and Confact Info: �'i � �'� ,/�p �� �Ca ��, _!�I ��� _„�/��- <br />_. , � , i „ 1_� �l�4L���_�--> <br />Prcperiy Address: <br />Pre-fnstallation Inspection Checklist: <br />AI! items must 6e checked 'Yes' in order (or a BWD to be considered tor installation <br />C7 <br />Is there a basemenl or level of the house that is a; or near assumed sewer main ele�•ation? �(es ❑ Yo <br />Are Ihere fixtures in the house Iccated beloe� the upstream se�xer marhole rim elevat�on7 [�%Yes ❑ No <br />'s tne side sewer currenfly UNPROTECTcD Irom setver bccicups (does not have a BVJD insfal!ed)? �Yes ❑ No <br />Site Inspeclion Checklist: <br />!+U riems must be checkeo 'Yes' Cefore inspection is consider�d complete <br />1'Jas side sev�er TV inspected from build'rng to sewer main? ',�'Yes ❑ No Condition: � <br />Oaes side sewer have at le2st t°b slope (rom the building to sewer main? I�Nes ❑ No Describe: _ <br />Have all bui!ding setiver drain connections to the side sewer been identified and located? [�Nes ❑ No � <br />Have all prcperty storm drainage connectlons to lhe side sewer been iden;ified and located? [�:Yes ❑ No <br />Nas :roperty been ovalualed for drainage defic'encies +vi(h findings communicated to propery owner?��'Yes ❑ No <br />Installation De ils: <br />�A�hat type and brantl o( BNJD was ins;ailed at Ihis site (Clean Check 3WV, Grinder pump, etc.): --u�l-- ` �Q <br />Where v�as Uie devir.e installed (general description, attach m2p)? �'(% ��- ��� �;�t.r ,�jC .6�1 I' 1-l— <br />VVas Ihere any other sewer or storm drainage work completed in conjunction �.viUi the BWD v�ork7 Is so please describe: <br />-- -- --- --�1J_l(1l7 <br />Installation Checklist: <br />Are all dowr�spouts and sile drainage disconnected from upstream of the 8WD7 �Yes ❑ P)o Comments: <br />Dces BWD positioning rneets minimum slope requirement oi>1%? �,Yes � y� Comments: <br />Can BWD be pulletl out for inspection antl mainlenance after loosening thumb screw? �,1,Yes ❑ No <br />Is BWD locked into the proper position and thumb screw lightened? �3res ❑ No <br />Cira� the BWD cover, rigavya_cof(k�nds .rape area)1 ha�ic loatl bearing cover (drive surface) / access hatch (building) <br />Nlas propeRy owner shoti�rn the localion�ihe iostalled BWD?�Yes ❑ No Commenls: <br />Prcperly Qemer's Signature: � <br />Inslailers Sigr,ature: <br />Revisinn: 2• <br />r <br />Date: �`' ' (�/� � C <br />Date: � U '—" <br />Priday, September 12, 2014 <br />