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�I�CKdVATER PREVENTION DE�'I�CE FII��►L <br />INSTALLATIaN CH�CKLI�iT <br />Installation Company Name and Cantact Info:,_,�.fj� <br />Date Backwater Prevention device (BWD) was installf <br />Installation PropeAy Owner Name and Contact Into: _ <br />Property Address: 7_ZZ �.� �- � <br />3+ <br />3�ii� <br />this form was compteted:s� 5� <br />'A!` <br />Prrinstallation In�peclion ChecMist <br />All items must 6e ctrecked 'Yes' :n order for a BWD to 6e consrderad for insfallafion <br />Is there a basement or level of fha house thal is al or near assumed sewer main etevation? �res � No <br />Are there fixtures in the house focated below the upstr�am sewer manhole rim elevation7 � 0 No <br />Is ihe side sewer currently UNPROTECTED from sewer backups (does not have a BWD irtsta�ed)9 [C�-Y� I"] No <br />Site InspecGon Checklist: <br />All Rems must be checked 'Yes' 6efo2 inspectian is consrdered compfete <br />Was side sewer N inspected from bu0ding to sewer main? �s ❑ No Condi6on: �-2J�-�� .�(� Q-`'� S <br />t)oes side sewer have at teast t% slope from the building to sewer main7 ��� No Describe: _ <br />Have all building sewer drain wnnections lo the side sewer been identified and Iocatedl (.�'es' 0 No <br />Have all property storm d2inage a,nnections to the side sewer been identified and located7 (g� ❑ No <br />Has p�perty been evaluated for drainage deficiencies w��h findings communicated ro properfy cw�e�? �s ❑ No <br />Installation Details: ��L <br />What rype and brand oi BWD was ins'ralled al ihis site (Clean Check BWV, Grinder pump, etc.): ' �-- - _ <br />Where was lhe device installed (general descripbon, attach map)? �— � h=-� ���5� Lr��� <br />Was there aoy other sewer or sto,m drainage work com��eted in conjunction wiih the 8WD �,aork7 Is so please describe: _ <br />InsYallation Checklist: <br />Are ell downspouLs and site drainage disconnected (rom upsUeam of the BWD7 es ❑ No Comments: <br />Dces BWD �silioning meets minimum slope requirement of >1%7 �s ❑ No Camments: _ <br />Can BWD be pulled out for inspec6on and malntenance after looseni��g thumb screN/t j�--Yes ❑ No <br />Is BWD locked into the proper pasi6o , rew 6ghtened? uJa'es U No <br />Cir�le the BWD caver. irrigation ver (landsca;� are tra�c load bearing cover (drive surface)1 access hatch (building) <br />'Nas pmpErty ovmer shown ihe locabon of the inslalled BWD? � Ye5 ❑ No Commenls: <br />• ��• 1 <br />Instailers <br />Date: I ^� S � � <br />Date. � � S � � <br />Revision: 2 1 Friday, September 12, .Ui4 <br />