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T BACKWATER PREVENTIOiV DEVICE FINAL <br />INSTAfI.LATION CHECKLIST <br />Inslallation Company Name and Contact In(o: �.;� �'�� r i5 �1.L� S �LV �1� i5 I!G� I_1�,�. , <br />Dale Backwaler Preveniion device (BWD) was inslalled:_ � �-��- 2olypate this form was completed;,�C -ZJ �� <br />Installation Property Owner Name and Cuntact Info: MAtZK �. I� c 5'�Qk'`� <br />Properh� Address: ���-� YVI c�� t,Pu- �s�/f ., �E� LvA C&2�> 1 <br />Pre�lnstallation Inspection Checklist: • <br />All items must be checked'Yes' in order (or a BWD l0 6e considered for installafion <br />Is Itiere a basement or level oi the house that is at or near assumed sewer main elevation? �❑ No <br />Are Iliere fixtures in the house located below the up:,tream sewer manhole rim elevation? �s ❑ No <br />Is Ihe side sewer currently UNPROTEL'TED from sewer backups (does not have a BWD installed)? �s ❑ No <br />5ife Inspection Checklist: <br />All ilems must be cliecked'Yes' be/ore inspection is conside�ed co plefe <br />Was side sewer N inspected (rom building to sewer main? Yes ❑ No Condition: ��� <br />Does side sewer have at least 1% slope from the building to sewer main? � s❑ No Oescribe: <br />Have all building sewer drain connections to the side sewer been idenlified and located? [�s ❑ No <br />fiave all properiy slorm drainage conneclions lo the side sewer been identified and located? [�es ❑ No <br />Has property been evaluated for drainage deficiencies with fndings communicaled to property owner? Yes ❑ No <br />Installation Details: <br />What type and hrand of BWD was installed at this site (Ciean Check BWV, Grinder pump, etc.)� C�EAn► C'+i�ECIG <br />Where was the device installed (general descriplion, attach map)? M�0 ta^���-4�b� <br />Wa:; Ihere any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe:(v� <br />Installation Checklist: <br />Are all downspouls and site drainage disconnected from upstream cf the BWD? es ❑ No Commenls: <br />Does BIND positioning meets minimum slope requirement of >1 %? [- Tes ❑ N� Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening Ihumb scre�v? �s ❑ No <br />Is BWD locked inlo ihe proper osition and ihumh screw tightened? _ es ❑ No <br />Cirr.le the BWD cover. irrigation cover (landscape area) raffic load bearing cover (drive surface) I access halch (buildinc�) <br />Was preperty owner shown the loca6on of ihe installz�WD? es ❑ No Comments: <br />Properiy Owner's Signature: <br />Installer's Signa�ure: <br />Itcvisian: 2 <br />Dafe: <br />Date: � � � 1 �1 J"tJl_ � <br />Monday, September 15, 2014 <br />