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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installahon Company Name and Conlact In(o: � <br />Date backwaler device (BWD) was installed�� <br />r <br />Installalion Property Owner Name and Confact Info: <br />ProperlyAddress: ��� �' L�Va <br />Dafe this (orm was <br />Pre-Installation Inspection Checklist: <br />AII ilerns musl te checked 'Ycs' in order for a BWD to be considered ior instalf3tion <br />Is there a basemen; or tevel of the house Ihat is at or near assumed sewec main eievation? � Yes ❑ No <br />A�� there fixlures in Ihe ir�use Iocaled below the upstream se�ver manhole rim elevation� �Yes ❑J No <br />Is the side sewer currenlly l,'NPROTEGTED from sev�er backups (does not have a BWD installetl)? [!] Yes ❑ No <br />Site Inspeclion ChecklisL <br />All items rnusl 6e chc•�ked'Yes' be/ae inspec6on is considered complete <br />N�as side sewer TV inspecled irom building to sewer main? �Yes ❑ Nn Condition <br />Does side sev�er have at least 1%slope (rom the building to sewer main7 �Yes ❑ No Descri6e: <br />Have all building sewer drain connections lo Ihe side sewer been idenlified and localed7 � Yes ❑ No <br />Have ali property slorm drainage connecfions te lhe side sewer been identified and localed? �Yes ❑ No <br />Has property been evaluafed for drainage defciencies ivilh fndings communicaled to property o�vner? [� Yes ❑ No <br />Instaliation Details: <br />What type antl brand of BWD was installed al lhis aite (Clean Check <br />Where was ihe device installed (general description, attach map)? � <br />Grinder �}�mp, elc.) ����QL�-- <br />14�as ihere any other sewer or stonn drainage work complefed in conjunclion wilh Ihe ABWD viork? Is so please describe: <br />Installation Checklist: <br />Are all downspoufs and site drainage disconneded (rom upslream of Ihe RWD? �Yes ❑ No Commenis. <br />Uoes BWV positioning meel minimum slope requiremenl 0(>1%?�Yes jJ No <br />Can BVJV be pulled oirf for inspeclion and maintenance a(ler loos niny lhumb screw7 <br />Is BNN locked into Ihe proper position and lhumb screw tighlened? <br />Yes ❑ No <br />Comments <br />�Yes ❑No <br />Circle ihe BWV cover. irrigstion cover (landscape area) / 7affic Ioa�T bearing cover (drive surlace) / access hatch (building) <br />VJas homeowner shovm the localion o( tho <br />Properly Owner's Si� <br />Installer's Signafurc: <br />❑ No Coinments: <br />_ Dale: J `�"�--5 <br />_ Date: ��2—iD �� <br />Revuion:7 6r I �hursday,Or.tober07,?OlA <br />