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�, B/�` CKNI.�TER PREVENTIOfV DEVICE FiNAL <br />� INSTALLATiON CHECKL�ST <br />r'n�r-� c� n�., .�-� G�r s� c'.c�'i 4 LG <br />Ins�alla�ion Company Name and Contact InFo:S� GC � r�' �zj;,7qly-C�S�� (� i�'t�i ,�F ,`�1 a���'�� <br />Dafe Backwater Prevention device (BWD) elas (nsf�lled:_ j�1__j Date Ihls form vras completed:.�_ <br />Installation Property Ovmer Name and Contacf Into:,�Q��`� � a�Gk"�L%] ��(o -�-]_(=G��� <br />PropertyP,ddress: ?�K��i i--�,l�- �,Je � ip,���(i ��� I <br />Pre•Installation Inspection Checkiist: <br />All Bems must be checked 'Yes'in order (ora tiWD to be considered for instaflarft,� <br />Is ihsre z 6asemsnt or Ievel of Ihe house that Is at or noarassumed sev.�er main elevalion7 �Yes ❑ No <br />Are there fixtures In Ihe house located 6elar� the upsiream sewer manho!e ri;n elevalion7� Yes ❑ No <br />Is the side sewer currenlly UNPROTECTED from se�ver backups (does no� have e BW� Installed)7 � Yes ❑ Nc <br />Slte Inspection Checklist: <br />AI( ifems m��st be checked 'Ves' before inspect/on is cons�dered comp;afe /� <br />Was sldo setver TV inspecled from bullding to sevrer main9 �'es ❑ No Condifbn: l�t'l�-i <br />�oes side sswer have at least 1% siopc� irom the building to seti:�er maln? [�Yes ❑ No Describe; i <br />Ha��e aG bui;ding sewer drain connections to Ihe side sewer bee�; !deMified and located7 �'Yes ❑ No <br />Have all property storm drainago connections to the side sevrer beon identifiad and Ioratad, [�-Yes ❑ No <br />Has prcperfy been evaluated tor drairage deficlencies with findings communicaied to properiy owneYl � Yes ❑ No <br />Installation betalls: �) <br />What lype and brand of B�ND was Inslalled at thls sile (Ciean Check BWV, Grinder pump, etc.):p ^ ,l� <br />Whoro �•�as the device instailed (goneral descripllon, altech map)7 � Y' ��y Q� G'�lL� , _��-� <br />bVes lhere.any other sewer or slorm dralnege worlc completed in conJunclion �si(h the 9WD work7 Is so pleaso descri�e: _ <br />Installatlon Checklist. <br />Are all doemspouis and site drainaga disconnested from upsUeam �.r the BNJD7 ,�]A'es ❑ No Commentx �. <br />Does BWD posflioning meets minlmum siope requirement o( >1%1 ��'es ❑ No Commenls: _ _ <br />Can BWD be pulled out for inspeellon and ma�ntenance aRer loosening Ihumb screw� Yes ❑ No <br />Is 6WD locked Into Ihe proper posllion and thumb screw Ilghtened? �Yes ❑�o <br />Cir�(e tlie BWD erTrrigellon c vo er landscape area) ! traKic load teadng cover (drive surla�e) I access hatch (bullding) <br />Ut�as proFerty ownor shoern Ihe localion of th�i7is(all BVVD7 k�'es ❑ No Commei�ls: <br />; �'%' �-��� � z�� - <br />Properfy Owner's Signature: Dale: � �� <br />j' ' ,_ — <br />Inslaller's Slgnature: _ �_ P/'c� Date: ' b a-�, __ <br />Revision: i• <br />Frlday, Septembcr 12, 2014 <br />