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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Insiallation Company Name ard Contact Info:_�L7z/1 P�rn/3ie�4 �d !e —��a— a�Z 9 <br /> Date Backwater Preven6on device(BWD)wzs installed: /Z- 2Z / Date this form�vas completed: /2—22— I� <br /> Inslallation Property Ovmer Name and Contac�In�: _ _ <br /> Property Address: _. � � <br /> Pre•Installation Inspection Checklist: <br /> Allitemsmustbechecked'Yes'inordcrfora "Jro6econsideredlorinsfallation <br /> Is there a basement or level of the house Ltiat is at or near assumed sev�er main elevation?Q'�es ❑No <br /> Are there fi�ures in lhe house located belo�v the upstream sewer manhole rim elevatiun?[�"�es ❑No <br /> Is ihe side sewer currently UNPROTECTE�from sewer backups(does not have a BWD installed)?�Yes ❑No <br /> Site Inspection Checkiist: <br /> Ail items must be:hecked'Ves'before i�spection is censidered complele <br /> VVas side sev�er N inspected from building lo sewer main? �'S'es ❑ No Condilion: G o�� PVG <br /> Does side sewer have at lea�t 1%siope from lhe b�iilding to se�ver main? �s ❑No Describe: <br /> Ha�e all building sewer drain connections to lhe side sewer been identfied and located? �es ❑ No <br /> Havt ali property slorm drainage connecfions to the side sewer been idenGfied and localed? �es ❑ No <br /> Has property been evalualed for drainage deficiencies with findings communi�ated to property owner? �1'es ❑No <br /> Installatior� Details: <br /> What type and brand o(BWD was installed at lhis site(Clean Check BWV, Grinder pump, elc.): C��an� CI�c;�� <br /> Where was the device installed(general description,atta map . <br /> VJas tnere any other sewer or storm drainage work compleled in conjuncBon�"�ith the BWD werk?Is so please tlescribe: Nc� <br /> Installation Checklist� <br /> Are all downspouts and sile drainage disconnecled(rom upstream of the BVJD? es ❑ No Comments: <br /> Does BN'D positioning meels minimum slope req�irement of>1%? �es ❑ No Comments: <br /> Can BWD be puL'ed out for inspecGon antl maintenance a(ter loosening lhumb screw? �Yes ❑No <br /> Is BIND locked into the proper positicn a�d thumb screw tightened? �'es ❑No <br /> e <br /> Circle lhe BWD cover: irrigat on�over(landscape area)I Vaffic load bearing cover(drive sudace)I aceess hatch (building) � <br /> Was property owner shovm the location of the inslalled BWD? �es ❑ No Comments: <br /> Property Owner's Signature: v�1�^"�l��"�'�l�� Dale: �2 � "�`f E <br /> Installer's 5ignature:��—� Date: � �- —�—� ' �� ; <br /> i <br /> Revision: 2 1 Tuesday, September 16, 2014 I <br /> 4 <br /> r <br /> I <br /> � <br />