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BACKWATER PRE�AENTION DEVIGE F iV <br /> E� INSTALLATION CHECKUST ��� �L�u�� <br /> '� A�'RZ02015 D <br /> :'U�L;C��Gx�KS <br /> Inslallation Company Name and Contact info: �v <br /> Date Back�vater Prevention device (BWD)was installed: `I- /s �� Date this orm v.�as completed:�_ <br /> Installation Property Owner Name and Coniact Info: ��Rs�� LMt��\��v� 1 1����. <br /> ProperlyAddress: ��7i� Lf'��hvrr� �i.�e�G11�- �hr <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Ves'in order Ior a BWD to be considered/or rnstallation <br /> Is there a basement or level o`the house lhaf is at or near assumed sevier main elevation'?�'Yes ❑ No <br /> Are ihere fxlures in the house located belo�r�the upstream sewer manhole rim elevation7 �Yes ❑ No <br /> Is ihe side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed}? [�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked 'Yes'before inspecfion is considered compfete <br /> !Nas side sev�er TV inspected from buildino to sewer main? �Yes ❑ No Condi�ion: Ca+�ual Gi�.K, IZm�c �3r1 o�t <br /> Does side se�ver have at least 1% slope from the building to seea2r main? {�Yes ❑ No Describe: . <br /> Have all building see�er drain conneclions to the side sewer been identified and lo�ated? �C] Yes ❑ No <br /> Have all properry storm drain- +connections to the side sewer been identified and localed? �Yes ❑ No <br /> Nas property been evaluatetl for drainage deficiencies�vith fintlings communicated to property owner? �Yes ❑ No <br /> Installation Details. <br /> 4Vhal type and brand of BWD was inslalled at this site (Clean Check BVtN, Grinder pump, etc.): ��P��,v� �ilw�� <br /> VVhere was the device installed (general description, allach map)?O�c�C ��5?� _ <br /> l�Jas there any other sewer or storm drainage vdork compleled in conjunction�vith the BWD work? Is so,�p,l(e�af$Q1 describe: <br /> �� ��Vue. n �w\L�.l ���v�S�ov� �'�U� Gtn ��Cf`��I�1 S� C St \ L�i�r1� Il� <br /> Installation Checklist: <br /> Are all dovmspouts and site tlrainage disconnected (rom upsiream of the BWD? [�Yes ❑ No Comments� <br /> Does BWD positioning meets minimum slope requirement of>1%? /[�-Yes ❑ No Commenls: ��,- <br /> Can BWD be pulled oul for inspecUon antl maintenance after loosening thumb screw? [�Yes ❑ No <br /> Is BWD locked inlo lhe proper posilion and thumb screw fighlened? �Yes ❑ No <br /> Circle Ihe 81ND cover: irrigation cover(landscape area)I IraHic load bearing cover(drive surface)I access hatch (builtling) <br /> Was property owner shown the location o(lh insla(led BWD? [,}�Yes ❑ No Cumments:��F�Rc�c(l�ge {�i .\,. <br /> r � <br /> Property Owner's � n ce: � Date:_3 � z� — �� <br /> Inslaller's Signalu � Dale: /� '— 2-3 �S <br /> ;f �� ,�� <br /> ftevision: 2 1 Friday,September 12, �014 <br />