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' BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ` �' ^P 5� 5C-��'�', L LC <br /> t'►'1Cr�Gczn �,� �c� <br /> Instalfation Company Name and Contact Info:1��F Qi ,N(1.��)�►Y'-� ��n;}"'�� ��'��3���:� <br /> Date Backwater Prevention device(BWD)was installed• Date this form was complet:d:6��— - <br /> Installation Property Owner Name and Contact Into:� .iA ag l �)IS �5 ,��1 S_�'__�a� <br /> Property Address: I `f� � �a-�l�(/ ��� �'� L�P/lQ� 1.��� �.�� � <br /> Pre•Installa6on Inspection Checklist: <br /> All items must be checked'Yes'in order(or a BWD fo 6e considered for insfalfation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?�Yes ❑ No <br /> kre there fixtures in the house located below the upstream sewer manhule rim elevation?�Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?�'Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked 'Yes'be%re inspection is considered complete ��� / <br /> Was side sewer TV insper.ted from building io sewer mainl �Yes ❑ No Condition: ���,�q� <br /> Does side sewer have at least 1%slope from the building to sewer main? (�(Yes ❑ No Describe: <br /> Have all building sewer drain connections to Ihe side sewer been identified and located? �Yes ❑No <br /> Have all property storm drainage connections to ihe side sewer been identified and located? �Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to properly owner? �'Yes ❑No <br /> Installation Details: <br /> What type and brand of BWD was Installetl at this site(Clean Check BWV,Grinder pump, etc.): G F <br /> Q�� � �, i <br /> Where was the device installed(yeneral description,altach map)? �('t" � �l7�-s-�-1-� <br /> Was there any other sewer or storm drainage work completetl i`n/co.n�ju,n,c/tion wilh the BWD vaork? Is so please describe:_ <br /> f`�({ I u� <br /> Installation Cheekiist: <br /> Are all downspouts and site drainoge disconnected irom upstream of the BWD? �Yes ❑No Comments: <br /> Does BWD posilioning meets minimum slope requirement of>t%? �Yes ❑ No Comments: <br /> Can BWD be pulled out tor inspection and main'enance atter loosening lhumb screw? �Yes ❑ No <br /> Is BWD locked into the proper.position and thumb screw tighlened? [�'es ❑No <br /> Cir;le the BWD cov : irrigation covei(landscape area)I tra�c load bearing cover(drive surface)I access hatch(builtling) <br /> Was prope�ty owner sho��m the location o e alled � .�'Yes ❑No Commenls: <br /> Property Owner's Signalure:' � Date:��//� <br /> Inslaller's Signaiure: �—� Date: ��al`�/I�- <br /> Revision:2 t Friday,September 12, 2014 <br />