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� <br />BACKWAl'ER PREVENTION DEVICE FINAL <br />INSTALLATION CHEClCLIST <br />Inslaliation Company Name anu Conlaci Info.. <br />Date B�ckwater Prevention device (BWD) tivas <br />I S Date this form v;as <br />Inslallalion Property Owner Name and Conlac� Info: ��Z� � �V� <br />Property Address: _ ,��q� + �`�- <br />Pre-Installation Inspection Checklist: <br />All itenrs rnust be checked 'Yes' io order for a 8WD fo be conside�ed far installa6c.v <br />� <br />Is there a basement or level of Ihe house lhat is a� or nezr assumed sewer main elevation? �f Yes ❑ No <br />Are ihere f xtures in ihe ho�se localed below ihe upstream seuver manhole rim elevation? � Yes ❑ No <br />Is ihe side sewer cunently UNPROTECTED (rom seiver backups (does not have a B�ND irstalletlJ? [� Yes ❑ No <br />Site Inspection Checklisl: <br />All ifems must b= checked'Yes' before inspection is %ronsitlered complete <br />Was si�e sewzr TV inspecled Irom buitding to se�v2r main? [�.l'es ❑ No Condition '�t '.Pt��" ¢`'�- �QOS-�C) <br />Dces side sev.er have at leest 1°6 slope from Ihe buiitling to sewer main? �I Yes ❑ No Descri6e; <br />Hzve a!I building sewe; drain connections to Ihe side se�ver been idenlitied and located? �j(] Yes ❑ No <br />Have all property slorm drainage connections to the side se:ver been idenlified and located7 [� Yes ❑ No <br />Has property been evaluated (or drainage deficiencies vaith fndings communicated to property oeener? Q Yes ❑ No <br />Installation Details: <br />�Vhat rype and brand of 9WD was installed al lhis site (Clean Check BWV, Grinder pump, etc.): �ci��t-�� <br />Where eras the device inslalled (general description, attach map)7 �51� f�l� t�Y'c�t i;Su'{- ._�4� <br />��las there any olher sewer or slorm drainage work completed in conjunction v�ith the BN�D work? Is so please de.scribe _ <br />Installation Checklist: <br />Are all downspouts and sile drainage aisconnected from upslream of the BWD7 � Yes ❑ No Comments: G tt ' 4bu}+�• <br />Does BWD positianing meets minimum slope requirement oi > 1%? � Yes ❑ No Commenis. _ <br />Can BWD be puiled out for inspection and mainlenance a(ter loosening lhumb screvR [�li Yes ❑ No <br />Is BWD locked inlo the proper posilion and thumb screw tightened? �Yes ❑ No <br />Circle the BVVD co��er: irrigation covei andsca_�) / tralfc load'uearing cover (drive sudace)1 access hatch (building) <br />N,�as properly owner shown lhe locali�n of the inslalled BWD? [J�Yes ❑ No <br />� ' �. _ <br />� ' � ( �. -- �- <br />Property Ovrner's Sign � � � <br />Inslaller's Signalure � <br />Comments: <br />Date: rL� ij ,>___ <br />Date: �s��7 — <br />�S <br />R�'sion: 2 1 `riday, Scptembcr 12, 2014 <br />