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� <br />BA�KWATER PREVEI�IToflN DEVICE FINAL <br />�NSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backv,ater Prevention device (BWD) v�as inst2 <br />Installation Prooerty Oemer MaTe and CoNact Info: <br />Property Address: <br />Date this form vras <br />Pre•Installation Inspection ChecMllst: <br />All items must be checked `Yes' in order for a BWD fo be cunsidered /or installation <br />!s ihere a basement or level of (he hcuse Ihat is at or near assumed sewer main elevafion? Yes [� iJo <br />Hre there fixtures in the house located belo�v lhe upslream s?:ver manhole rim elevation? 1'es ❑ PJo <br />Is the side se�,ver curremiy IJNPROTECTED from =etiver backups (does not have a BI��U instatled)? [� Yes ❑ No <br />Site Inspection Checklist: <br />AI' i!ema must be ebec!!ed Yes' 6e(ore inspection is considered compfate <br />b?'as side setver N inspecied irom building to se�rer main? � Yes ❑ No Condifion: <br />Does side sev:er have at leas( 1°/o slope irom the building to sewer main7 � Yes ❑ No Descrbe <br />Have all bwlding sewer drain connections to lhe side secrer been identifed and located7 �J Yes ❑ No <br />Have all properly storm drainage connections lo the side sewer been identifed and located7 (� Yes ❑ No <br />Has property been evalualed (or drainage defir.�encies v�ith (indings communicated to property oe+ner? �I Yes ❑ No <br />Installation Details: <br />!Nhat type and brand of BWD �vas installed at lhis si Clean CI eck WV, Grinder pump, etc.). <br />N:here was ihe device installed (general descriplion, aitach map)? <br />Vdas Ihere any other sev�er or storm drainage v�ork completed in corijur� ion eaith the BWD �;�ork7 Is so please describe _ <br />—4-'���--- <br />Installation Checklist: <br />Fue ail do��:nspouls antl sile drainage disconnecled �rom upstream of Ihe BWC? �Yes ❑ Ne Commei�ts• _ <br />Does BWD positioning meets minimum slope requiremenl 0(>1%? ,� Yes [] No Commenis: _____ ______. <br />Can BWD be pulled a�t for inspe�tion and maintenance afler loosening Ihumb screve? �Yes [j No <br />Is BWO locked inlo the proper position and thumb scree� tightened? _�j Yes ❑ No <br />Circle !he BWD cover. irrigation cover (landscape arca)1 traffc load bearing cover (dnve surface) I access halch (building) <br />�:Vas property o�vner shown the local�on Ihe installed BN1D? �j Yes ❑ No Comments __ <br />Property Owner's Signa " ��•"'` ��z�`��'"� Daie: �17v �2. 7��� 7, <br />1 / <br />Installer's Signature: _ .���_ Date I �_' Z�7' ��7 <br />� <br />Revision: 2 (,; �V 1 friday, Seplcinber 12, 2014 <br />S <br />