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i <br /> I <br /> BACKWATER PREVENTiON UEVI�E FINAL ; <br /> INSTALLATIaN �HECKLIST <br /> � � <br /> / i <br /> InstallaGon Cnmpany Name and Contaet Info:��/�;�� �d7 � C_. ���T- �� s- DjZ 3 , <br /> Dale Backwater Prevention device(BWD)was installetl: -/ -/ � Date this form was complete�i: �/ �[$— ! <br /> � <br /> i <br /> Installafion Froperty Owner Name and Contact into: ci'�' <br /> i <br /> Property Address: � y� U �'�+-�iT fF�'I� � <br /> Prtilnstallation Inspection Checklist: � <br /> All items must be checked'Yes'in order for a�WD to be considered for rnstalfafion � <br /> Is there a basement or level of lhe house tha(is at or near assumed sew:r main eleva6on? � ❑No � <br /> Are lhere fixtures in Ihe house localed helow the upstream sewer manhole�m eleva8on? � es ❑ No � <br /> Is fhe side sewer currently UNPROTECTED from sewer backups(does not hava a B�VD installed)?�'f-es ❑No � <br /> Site!�ispestion Checkitst: I <br /> I <br /> All items must be checked'Yes'be(ore inspecfion is considereu complete / ! <br /> Was side sewer TV inspected irom building to sewer main? [�'es ❑No Condifiorr. � !^� �v �! ' <br /> Does side sewer have at least 1%slope from the building to sewer main? es ❑ Nc Describe: � ; <br /> Have all building sewer drain connections to the side sewer been idenfified and located? (l].-YEs ❑No <br /> Have all property storm drainage connections to lhe side sewer been idenfi�ed and located7 [�-Ycrs ❑No � <br /> Has prope�ty been evaluated for drainage deficiencies wilh findings communicaled to property owner? 0�`{e� 0 No ! <br /> Installation Details: �/�� � <br /> What type and brand of BWD was installed at this site(Clean Check BW�V, ��rin�der pump,etc.):_{.�._��`-���C - � <br /> Where was Ihe device installed(general description, aUach map)? �-o--e_ ✓1'�14-/� ' <br /> I <br /> Was ihere any other sewer or stortn drainage woric compleled in conjun�lion wilh the BWD work?Is so please describe:_ ; <br /> .�l(y�� - <br /> Installation Checklist: ' <br /> Are all downspouts and sife drainage disconnected from upslream o(Ihe BVJD? [�'�s ❑No Comments: • <br /> Doas 3WD positioning meels minimum slope requiremenl oF>19'o? [�Ja`� ❑No Comments: _ <br /> Can BWD be pulled out for inspeclion and mainlenance after loosening ihumb screw% �i-�fes ❑No � <br /> Is BWD locked into the proper position and thumb screw lightened? (]-Yes ❑No � <br /> Circle Ihe BWD wver.irriga6on cove landscape area}�Uaific load bearing cover(drive sur(ace)I access hatch(building) � <br /> �---- i <br /> W�s property owner shown the location of ihe installed BWD? � es ❑No Comments: � <br /> Property Owner's Signature:�.�� lM `------ �- Date��� � �� i <br /> Inslailers Signature:��___ _ Oate: (�r,-1"?- I S,r ; <br /> Revisinn:2 1 Friday,September 12, 2D14 <br /> I <br /> I <br />