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1 <br /> ��� , <br /> ��_�� BACKWATER PFtEVENTION DEVICE FINAL � <br /> INSTALL.ATION CFiECKLIST' <br /> � !� � < � � 9-o(z3 <br /> Installalion Company Name and Contacl Info�� N <br /> Date Backwater Prevention device (BWD)was inslalled:_. —� l d�—I��B le Ihis form v�as completed: . '��—)�� <br /> Installation Property Oe+ner Name and Contacl Inio: � % ��� '/«VU �y� <br /> Property Address:_ �,� � �� <br /> Pre-Installation Inspection Checklist: <br /> !il!ilems must be checked 'Yes'in order for a BWD to be conside�ed lor installation <br /> Is there a basemenl or level o(the house thal is at or near assumed see✓er main elevetion? 0� ❑ No <br /> Are there fxlures in the house located belo�v the upslream sev,er manhole rim elevation? es ❑ No <br /> Is ihe side se�ver wrrently UNPROTECTED irom sev�er backups(does no[have a BWD installed)? Ll.�-Y�es ❑ No <br /> Site Inspection Checklist: <br /> All items rnust be checked 'Yes'6efore inspecfion is considered complete ��� _ <br /> VJas side sea+er TV inspecled from building to setiver main? (_�es ❑ No Condition:_�/1_9''�=`'��� <br /> Does side sevrer have al least 1% slope from the building lo sev�er main? [}-Y'es ❑ No Descr e:_ � <br /> Have all building sewer dra�n connections lo ihe side sewer been idenlified and located? [�Xes ❑No <br /> Have all proparfy storm drainage conneclions lo the side sev�er been idenlified ar�d localed? [�-1`e�� No <br /> Has property been evaiva�ed for drainage defciencies�vilh fmdings communicater:to property owner? �Yes ❑No <br /> Installation Details: �� <br /> 1r�'i�al lype and brand oi BVJD was inslalled at lhis sile(Clean Check BlM/, Grinder pump, etc.):� ��-,�— �✓�—_�� <br /> 1^:here�vas lhe device instalied (general desc,ription, altach map)? cS�GL� (�2N1�/uA ( N-F"��� <br /> l�Ja;ihere any olher sewer or s�orm drainage work completetl in conjunclion wilh the BVJD wcrk? Is so please describe� _ <br /> _-w�- - _ <br /> Installation Checklist: <br /> Are all downspouls and sife drainage disconnected from upsiream of Ihe BWD7 L�'� ❑ Wc Cnmments: __ <br /> Dnes BWD posilioning meets minimum slope requirement o(>1"/0? �`P.s ❑ No Commenls: ____ <br /> Can BWD be pulled oul(or inspeclion and mainienance aiter loosening thumb screw7 rj�'es ❑ No <br /> Is 6WD locked into Ihe proper posilion and lhumb screw lightened? r4�N�s ❑No <br /> Circle Ihe BVVD wver. irrigalion cover(lantlscape are tra(fic loatl bearin cover rive surface)I access hatch (building) <br /> Was properly owner shown Ihe Iocation o(Ihe inslalled BWD? �L] No Commenls: <br /> Pwperty Owner's Signatur Date: 3"-��� 5 <br /> Installer's Signa;ure: � �— Date: �� �� � <br /> Nr�lsion: 2 1 Friday,September 12, 2074 � <br />