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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Inslallation Company Name and Conlact Into:� ����,m���_� t �- �IZ s' <I Q�� -D i Z3 <br /> Date Backwater Prevention device(BWD)�vas inslalletl: I-�- � 5 Dale this fortn vras completed: I -�2- 1 S <br /> Instailation Properry Owner Name and Conlacl Into:�u� PerrE'�Y� <br /> PropertyAddress: ���� ��Y N��n-1�,.�, �lei-J pi2�u� f=�.vK+"'e v�,4 <br /> Pre-Installation Inspection Checklist: � <br /> Ail ifems must be checked'Yes'in order lor a BWD fo 6e considered for insfallafion p <br /> Is lhere a basement or level of ihe house ihat is at or near assumed se�ver main elevation? es ❑No ' <br /> Are there fixlures in lhe house located below the upslream sewer manhole rim elevation? [t}�'�s ❑No <br /> Is;he side sewer curren0y UNPROTECTED from sewer backups(does not have a BWD installed)? es ❑No <br /> Site Inspection Checklist: <br /> All ifems must 6e checked'Yes'before inspecfion is considerad complefe ` <br /> Was side sewer N inspecled from building to setiver main? [a'�s ❑ No Condition: �'7 a'*' C e"`c''�'� .I <br /> I <br /> Does side sewer have at least 1%slope from ihe building to sewer main? f�fes ❑No Describe: � <br /> Have all building sew2r drain connections lo the side sewer been identified and located? es ❑No <br /> Have ali properly slorm drainage connections to the side sewer been idenlified and localed? es ❑No <br /> Has properly been evalualed for drainage deficiencies with findings communicated to property owner? [�'fes ❑No <br /> Installation Details: <br /> Whal type and brand o(BWD was instailed al this sile(Clean Check BVW,Grinder pump,etc.): C I-eo�-Gl.t c �� <br /> Where�vas the device installed(general descriplion,allach map)? _I�-K-'r '� ��� S� — � <br /> y' �}r'►� `�e- �i�cwk d�v <br /> Was there any olher sewer or stortn drainage work completed in co�pclion v�ilh 1he BWD vrork?Is so please describe:_ <br /> � � - <br /> Installation Checklist: �u��'h�r^er--` <br /> Are all downspouls and site drainage disconnecled from upslreara of the BWD? es ❑No Commenls: lrJ�S L���F <br /> Does 8WD positioning meels minimum slope requirement oi>1°" [1�.�'� ❑No Commenis: <br /> Can BWD be pulled out for inspection and maintenance after loosening Ihumb screw? es ❑No � <br /> Is BWD locked into ihe proper posilion and 1 ew tigh�ened? es ❑No <br /> Circle tlie BWD cover: irrigalion cover dsca traffic load bearing cover(drive suriace)f access hatch(building) <br /> Was propedy owner shown lhe location ot the installed BWD? � �No Comments: <br /> � Dale: / -/2-i � <br /> Property Ovmer's Siyna ? <br /> IoslallersSignatu • Date: �-�--�.� <br /> Revision: 2 1 Friday,September 12,2014 <br />