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BACK�NATEf� PREVENTfON DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: V–t-n�)�I CJ h'�Ll Wld1 ��� <br /> Date Backwater Prevention device(BWD)was installed:`6 z 8 Date this form was completed: c1 � <br /> �n S <br /> Installation Property Oti�ner Name and Contact Infa_1L��( �n rn�(' �'�n � � <br /> PropertyAddress:�l�l3� Lo�� a�oQr�� • <br /> Pre-Installation Inspection Cfieckiist; <br /> NII items must 6e checked'Yes'in order(or a BIND to 6e consider�d for installation <br /> Is ihere a basement or level of the house that is al or near assumed sewer main elevation? [�Yes ❑ No <br /> Are there fixfures in the house lorated below the upslream sewer manhole rim elevation? [�Yes ❑ No <br /> Is the side sevaer currenUy UNPROTECTED from sewer backups (does not have a BWD installed)?�Yes ❑ No <br /> Sit;: Inspection Checklist: _ <br /> All items must be cliecked`Yes'6efore inspection is considered complete <br /> Was side sewer N inspected from building to sewer main? (�]Yes ❑ No Condifion: <br /> Does side sevder have at least 1%slope from the buiiding to sewer main? �]Yes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been i�ientified and located? �Yes ❑ No <br /> Have all properry siorm drainage connections to lhe side sev�er been idenffied and lo�ate 7 [�Yes ❑ No <br /> Has property been evaluated for drainage defciencies vailh findings communicated to properfy o�vner? �]Yes ❑ No <br /> Instaliation Details: <br /> What type and brand of BWD was ins�alled al this s'�e(Clean Cheok BVJV, inder pump,etc.): <br /> Whe�e was Ihe device installed (general descriplion, afl�h�mapj. I�ac.k���.� ��n �����-�^-��--- <br /> Was there any olher sower or storm drainage work compleied in conjunction v�ith ihe BWD�aork? is s/ please describe:_ <br /> �1 P5 r o�n�..eC,�� ��� o��� c Gt-c P� nl�m�tSac�u`�. <br /> InstallationChecklist: lo��rc��2� I�ol.�� S��l��kqk�� <br /> Are all downspoufs antl sife drainage disconnecled from upstream�f the BWD? [�Yes ❑ No Commenis: <br /> D�es BWD positioning meets minimum slope requirement of>1%? Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection antl maintenanco a(ter loose ing lhum6 scre�v7 �]Yes �No <br /> Is BWD locked into the proper posilion and thumb screw tighlened? [�Yes ��Je----� <br /> Circle the BWD cover: irrigalion cover(landscape area)1 t ffic I ad bearing cover(drive surface)!a ss hatch(building) <br /> Was properfy owner shown the localion of the installed BWD7 ' es�-No—Comments: <br /> Property Owners Signalure: � Dale: <br /> Insfallers Signature: � �ate: c1 I�� � 'i <br /> Revision: Z 1 fri�i�y,September 12,2014 <br />