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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION �HECFCLIST <br /> Ins4,llation Company Name and Contact Info:,12/�O ���* •-�3'� Q <br /> Date Back�vater Provention device(BWD)was Instailed: 3�i��/r Date this fortn was completed: � � � �.� <br /> Installation Property O�vner Name and Contact Info: �� /�i �G dr-• <br /> Property Address: ZS/7 r�<r�''�L <br /> Pre•Instailation Inspection Checklist: <br /> All items must be checked 'Yes'in order for a BWD to be considered forinstella6on <br /> Is there a basemenl or level of the house that is at or near assum�1 sewer main elevationl dYes ❑No <br /> Are lhere fxlures in the house located 6elow ihe upstream sev+er manhole rim elevalion?�/]Yes ❑No <br /> Is the side sewer curtently UNPROTECTED from setiver 6ackups(does not have a BWD installed)�Yes ❑ No I <br /> Site Ir.specfion Checklist• <br /> All items musf be checked'Yes'before inspection is considered compfete <br /> Was side sewer 1V inspected from building to sewer main? Yes ❑No Condition: <br /> Does side sewer have at least 1°/a slope trom the building to s�er main? [�'Yes ❑No Describe: <br /> Have all building sewer dr�in conneclions to the side sewer been Idenlified and located? �Yes ❑ No � <br /> Have all property storm drainage con�e�tions to Ihe side sewer been identified and locatad? [�i'es ❑No <br /> Has preperty been evaivated for drainage defciencies with iodings communicated to property owne(l �Yes ❑No <br /> Instaliation Details: <br /> Whai type and brand ot BWD was installed at this ite(C�i an C ec nder pump,etc.): <br /> Where v�as lhe device installed(general descriplion,attach map)? <br /> Was ttere any olher sev+er or slorm drainage work complete In conjunclion wilh ihe BWD worit?Is so please describe:_ <br /> �I/ — <br /> Installalion Checklist: � <br /> Are all downspouts and site drainage disconnected irum upstream of ihe BWDT f�Yes ❑No Comments: <br /> Does BWD posilioning meels minimum slope requirement ot>1%7 p Yes �No Comments: <br /> Ca�BW�ba pulled out for inr�peclion and maintenance aRer loosening lhumb saew7 �'Ves �]No <br /> Is BWD Iecked into t�he r pe�esifien�nd-Ib screw ti htened? �Yes ❑No <br /> Circie the BWD coJer;�irsigaGon�eover j1 naJ d�jT�aKc load bearing cover(drive surface)/access hatch(building) <br /> Was property o�vner shovm the localion of lhe installed 3WD9 (�Yes ❑No Comments: <br /> Property Owners Signatur ` `--�— Date: �//�� <br /> � Inslallei s Signalui � Dale:_„31����� <br /> Revision: 2 1 Frfday,September 12,2014 <br />