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. � .. i <br /> BACKWATER PREVENTION DEVICE FINAL <br /> � INSTALLATION CHECKLIST <br /> Installation Company Name and Conlacl Info: tt(��b PLt�„vi c3io✓lo C. <br /> Dale Backvaater Prevention device (BWD)was installed: �— Zg —�1Tate this(orm�vas compleled: S� 3 - i r <br /> Installation Property Ovmer Name ard Contact In`o: C7(.//_S�� / /�2�p�C' <br /> PropertyAddress: I �P4I Lovv�t3v}�2-F? f4-t/cs (��l. L-+2e'T7' C�✓44- Z82o � <br /> Pre•Installation Inspection Checklist: <br /> Afl ifems must b�checked 'Yes'in order for a BWD lo be considered/or installation <br /> Is there a basement or level of the house that is at or near assumed sewer mair� elevation?�,Yes ❑ No <br /> Are there fxtures in the house located below Ihe upstream se�,ver manhole rim elevation? 7�Yes ❑ No <br /> !s the side sewer curren;ly�UNPRO7ECTED irom se�ver backups (does not have a BWD installed'? �.j'es ❑ No <br /> Site Inspection�hecklist: <br /> A!!items must be checked'Yes'before inspection is consrdered complete <br /> Was side sewer N inspecled irom buiiding to sewer m:,in? �Yes ❑No CondiGon: ��C �'��-�-�=`"r L <br /> Does side sewer have at least 1%slope from ihe b��ildiny to sewer main? �.Yes ❑ No Describe: <br /> Have all building sewer tlrain connections to the side sewer been ideniified and located? `�,yes ❑No <br /> Have all property siorm drainage connec6ons to the side sewer been identified and loc�ied? (�Yes ❑No <br /> Has property been evaluated for drainag�deficiencies with findings communicated to property ovdner? �Xes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was inslalled at this sile (Clean Check BWV,urinder pump,etc.):C(.LrROJ C�(sGK <br /> INhere was the device installed (general descripti , attach map)? __ <br /> UJ2s there any other sewer or storm drainage work completed in conjunction wilh the [3WD aork? Is so please describe:�� <br /> Installation Cher,klist: <br /> Am all downspouts and site drainage disconnected from upstream of the BWD? ��Yes ❑ No Comments: <br /> Does BWD positioning meels minimuin slope requirement of>1%? �Yes ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenan�e after loosening thumb screw? �Yes ❑ No <br /> Is RWD locked into the proper pesition and thumb screw tightened? ,�Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load 6earing cover(drive suriace)/aecess halch (building) <br /> Ut�as property owner shown the location of the installed BWD? �Yes ❑ No Comments: <br /> �i%.E) �,,,,,,r,,, <br /> Property Ovmer's Signature: (��1 d,,,���/��� Date: '� S �� <br /> Installer'sSignalur : � Date: S='3 � �S— <br /> Revision: 2 1 Tuesday,teptember 16, 2014 <br />