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� BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLiST <br />Installa9on Company Name and Contact Inio: L b►rl Z=� � 8 — dl Z7 <br />Dete Backwater Preventinn device (BWD) was �nstalled: y—�ri-1 �_ Date this tortn was completed: �—�� � <br />Ins�llation Propedy Oumer Name and Conta�l Iniu: '�'\ 1 S'�i1 �-Ti��g�� � � <br />F��petty Address: <br />Pre-In�llation Inspecdon Checldisr <br />All items must De checked 'Yes' in order for a BWD to be consfdered for installation <br />Is there e basement or level ofthe house that is at or near assumed sewer main elevaUon? [� ❑ Na <br />Are there foAures in the house loqted below the upstream sewer menhole rim elevation7 Cl'f'� :[] No <br />Is the side sevrar curtently UNPROTECTED from sewer b�.�cups (does not have a BWD inshalle�? �Xes ❑ No <br />Site Inspection Checklist: <br />All ifems must be c8ecked 'Yes' Defore inspecSon is cansiderod awnplete <br />Was side sewerN inspected from buiWing to sewermain7 �� No <br />��� <br />Condition: D1�.��E"O'� <br />Does side sewer have at least t% slope (rom tlte buiiding to sewer main? �1`e�� No Desqibe: <br />Have all Guilding sewer drain �nnecUons to the side sewer been identified and located? �-1`e� 0 No <br />Have ali property stortn dreinage oonnectfons to ihe side sewer been Identified and bceted? �(]Ye�—� � <br />Has propedy been evaluated for drainage deficiencies w�h findings com: iunicated to propedy owneR �� No <br />Installation Detalls: <br />What type end brand of 8WD was inshalled at fhrs sil Clean Che� <br />Where was the device Inshalled (general des�xip8on, attech map)? <br />etc.): C�cu-G� �etL <br />Wa� ihere any other sexrer or erorm dralnage work completed in conjundion v�rilh She BVY�J wor1C? Is so please describe: _ <br />A I „-,,. o -- <br />Installadon Checklist: ,--,,,� <br />Are all doumspouts and site drainage disconneeled irom upsUeam of tAe BWD? �res � No Commenta: <br />Does pWD positloning meeLs minimumslope requirement of>1%? ((��0 ��m�^�� <br />Can BWD be pulled out for fnspection and maintenanoe after loosening thumb stxeu�? [�1Ges- 0 No <br />ts BWD loeked f�o the proper positian and tfiumb s�xew 6ghtened? [�-Ye�[] No <br />Ci�le the 8WD oover. irtigation co pandseape a�ee t�c load bearing cover (drive surFace) I ascesa hatch (bullding) <br />Was p�opeAy owner shown tlre location of the Instalisd BWD? [�}'i'� � No Comments: <br />Properry Ovme�'s Signa �e: Dale: ���� <br />Installers Signatu�e� • <br />� Date: 'S� �O� � <br />Revision: 2 1 Friday, Septemher 12, Z014 <br />