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`, , , <br /> ' � BACF�WAI'��t PREVENTION DEVICE FIfVAL <br /> ,� IN.�'i�'ALLATION CHECKLIST <br /> Inslallation Company Name and Contact Info: �e:�r�1�P1�'ti �1v�,1�',r�+ <br /> Date Backwater Prevention device(BWD)was installed: '�'�� Date this form was completed: —S —�� <br /> Installation Property Owner Name and Contact Inio: I�t�P�.T �/��So� <br /> Property Address:�,�`Z� •Lp��� �NE-. �J� �"� q.�sZD 1 - <br /> Pre•Installation Inspection Checklist; <br /> All items must be checked'Yes'in order for a BWD to be considered for installation <br /> Is there a basemenl or level of the house thaf is at or near assumed sewer main elevation? [✓]�Yes -� No <br /> Are there fixtures in the house located be!ow the upsiream sewer manhole rim elevation?�Yes ❑ o <br /> Is!he side sewer currently UNPROTECTED from sewer backups (does not have a BWD insialled)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items musf be checked'Yes'before inspection is considered complete <br /> Was side sewer N inspected from building to setver main? es ❑ No Condition: C'�ob� <br /> Does side sewer have at least 1%slope.from the building to sewer main9 �res ❑ No Describe: <br /> Have all building sewer drain conne�tions to the side sewer been identified and located? Yes ❑ No <br /> , Have a!I property storm drainage connections to lhe side sewer been identified and located? es ❑ No <br /> Has property been evaluated for drainage deficiencies with flndings communicated fo property o�Nner? es ❑ No <br /> Installation Details: � <br /> What type and brand of BWD was installed at this sife(Clean Check BWV, Grinder pump, elc.): �� �-� <br /> Where was the device installed (general description, atiach map)? M� �� <br /> Was�here any other sewer or storm drainage work completed in conjunction with the BWD worK?Is su please describe:_ <br /> N C�'{�Fv <br /> Installation Checklist: DwN�. <br /> P�b���' <br /> Are all downspou(s and sife drainage disconnecled from upstream of the B 7 �s 1� No Comments:_���'� <br /> Does BWD posilioning meets minimum slope requirement of>1%? Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thu screw? �fes ❑ No <br /> Is BWD looked into the proper position and thu w tightened? . es ❑ No <br /> Circle the 6WD cover; irrigalion cover(a �scape ar iraffic load bearing cover(tlrive surface)1 access halch (building) <br /> N1as property owner shown ihe I ion of the' talled BWD? es ❑ No Comrrenls:_ <br /> Property Ovrner's Sign u Date:_�2—�r—Z° � � <br /> Installers Signalure: _ Date:��^ � 2-vi�_ <br /> Revision:2 1 Monday, September 15, 201h <br />