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�, <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />�+C;r�; <br />I t II t' Com an Name and Conlact Info: ��'1P_ �"1 C'�. Yl � <br />ns a a ion p y � � <br />Date Backwater Prevention device (BWD) was installed: ,a�_ Date ihis form was completed: �� <br />Installation Property Owner Name and Contact Into: �,� �� ��� � 7�-r•�/a <br />Property Address: <br />Pre•InstallaHon Inspection Cheoklist: — <br />All items must be checked 'Yes' in order for a B WD to 6e considered for irstallation <br />Is tliere a dasement or level of the house that is at or near assumed sewer main elevation? � Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhofe rim elevation?,�] Yes ❑ No <br />Is the side sewer currently UNPROTFCTED from sewer backups (does not have a BWD ins!alied)? (� Yes ❑ No <br />Site InspecHon Checklist: <br />All items must be checked'Yes' before inspection is considered complete <br />Was side sewer N inspected from building to sewer main? � Yes ❑ No Condition: <br />Does side sawer have at least 1% siope from the building to sewer main? � Yes ❑ No Describe: <br />Have all building sewer drain connecfions to the side sewer been identified and located? ,� Yes ❑ No <br />Have all property storm drainage connections to the side sewer been iden6fied and located? �Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? �Yes ❑ No <br />Installation Details: •� 5,,� � <br />What type and brand of BWD was installed at this sife (Clean Check BWV, Grinder pump, etc.): n�'-��^ � <br />Where was the device installed (genera! description, atlach map)? ��[� CY�PEoC%0����C� �'i� <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br />Installa8on ChecklisL• <br />Are all downspouts and site drainage disconnected from upstream of the BWD? �Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of>1%7 � Yes ❑ No Comments: <br />Can BWD 6e pulled out for inspection and maintenance after loosening thumb screw? � Yes ❑ No <br />Is BWD locked into the roper position an�l thumb saew dghtened? JZQYes U No <br />Circle the BWD cov r: irtiga6on cover nelsrape area)1 Va(fic load bearing cover (drive surface)1 access hatch (building) <br />Was property owner shown the location o( the installed BWD? �Z(Yes ❑ No Comments: <br />Property Owners Signature: � � Date: I�- �S —' <br />Instaliers Signature: Date: ' � _ <br />Revision: 2 <br />Friday, September 12, 2014 <br />