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BACKWATER PREVENTION DEV'ICE �INAL <br /> INSTALLATION CHECKLNST' <br /> Installation Company Name and Confact Inio:�� �rn f?i_�/s �125" y �7`3 -G! Z? <br /> Date Backwater PrevenUon device(BWD)was inshalled: /�ot�!.�Date this form was completed: r-a g—�5 <br /> Installation Property Owner Name and Contact Info: l..Q ci-n r� t}w 9 `�a-'rt� <br /> PropertyAddress: 2S-<< 1�'`a�Q � �� --��v.��- <br /> Pre-Installetion Inspection Checkiist: <br /> All itens must 6e checked'Yes'in order for a B WD to be considered for installa6on <br /> Is ihe�e a basement or level of the house that is at or near assumed sewer main elevatfon7[�}'f8s ❑No <br /> Are there fixtures in the house located below the upslream sewer manhole rim elevation?�Yes ❑ No <br /> Is ihe side sewer currenUy UNPROTECTED irom se�ver backups(does not have a BWD installed)?�-1'es ❑No <br /> Site InspecHon Checklist: <br /> All items must 6e checked'Yes'6e(ore inspecfion is considered complete <br /> Was side sewer N inspected from buflding to sewer main? �(�es ❑ No Conditlon: 1�2� i <br /> Does side sewer have at least 1`Yo slope from the building to sewer main? es � <br /> ❑No Describe: <br /> Have ali building sewer drain cannections to ihe side sewer been identified and located? [t]'f�s ❑No <br /> Have all property storm drainage connections to the side sewer been iden8fied and located? [�'1�es ❑No <br /> Has property been evaluated for drainage deficiencies wifh findings communiqted to properiy owner? [}Yes ❑No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): �����'�-�-�%� <br /> Where was the device installed(general descrip6on,attach map)? piA-rL��`� 6��� <br /> L4-Ne�,��a'�- - <br /> Was Ihere any other sewer or stortn drainage�rk��ete�i in conjunction wilh the BWD worK?Is so please describe:_ <br /> Installation Checklist: <br /> Are all downspouts and sile drainage disconnected from upsUeam of fhe BWD? es ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>t%? �es ❑No Comments:_ ; <br /> Can BWD be puUed out for inspection and maintenance after loosening thumb screvJl [�es ❑No i <br /> i <br /> Is BWD locked into Ihe proper p�sition and lhwnb screv�li htened? -�N � <br /> Circle the BWD cover: irrigation cover(landscape area) �ic load bearing cover(drive surface /access hatch(building) <br /> Was properiy owner shown the locabo of fhe installed BWD? (�� �No Commenls: <br /> PropeAy Owne�s Signature• ' Date: � '� Z�`-�5 <br /> Installers Signature: r Da�: l�� �S <br /> Revision:2 1 Friday,September 12,2014 <br /> 1 <br />