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BACKWATER PREVENTION DEVICE FINAL <br /> �, INS1'ALLATION CHECKLIST <br /> Installation Company Name and Contact Info: il i�o iio I�/a r+i3�,. .; /L�z s � 3 5' �So7 <br /> Dale Backtvater Prevention tlevice(BWD)was inslalled: " 3 � Date this form was completed: /-f <br /> Uzs> <br /> Installation Properly Owner Name antl Contacl Info: �-acr�3- i7 e�,n L�zM 1��'�'T �iy� �s'v <br /> Properiy Address: l�x/ Du�'r.3' i v��i���' t�v�- ��z�/ <br /> Pre•Installation Inspection Checklist; <br /> kll items must 6e checked'Yes'in order lor a BWD to 6e considered for installation <br /> Is there a basement or level of llie house that is at or near assumed se�ver main elevation?�Yes� ❑ No <br /> Are there fiztures in the house located belov✓the upstream sewer manhole rim elevalion?�Yes ❑ No <br /> Is the side sewer currently UNPROTECTED(rom sevaer backups (does net have a BWD installed)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complete <br /> Was side sewer TV inspecled from building to sewer main? �Yes ❑ No Condilion: <br /> Does side sewer have at Ieast 1%slope from tiie building lo sewer main? �/]Yes ❑No Describe: <br /> I lave ail 6uilding sevaer drain connections to fhe side sevaer been identified and located? f]/�Yes ❑ No <br /> Have all property storm drainage connections to Ihe side sewer been identified and localed? �'Yes ❑No <br /> Has oroperty been evaluated(or drainage deficiencies ti�ith(indings communir.ated to properiy nwner? �Yes ❑ No <br /> Ins!allation Details: <br /> 1Nhat rype and brand of BWD was installed at ihis site(Ciezn Ch��ck[3WV, Grinder pump, etc.):A�8 s j��'/ <br /> a�here a�as Ihe device installed(general descriplion,a�lach map)? jn' rpc� /3ul�r'� �n� G�-F <br /> •/!�G /+u•:� S4uC.� <br /> 1Nas Ihere any other setaer or storm drainage work completed in conjunction�vilh the BWD work?Is so please describe _ <br /> ��� <br /> Installation Checkiist: <br /> Are all dovmspouls and sile drainage disconnected from upstream o(the DWD? �Yes ❑ No Commcnls: <br /> Does Ql4�D positioning meels minimwn slope requirement o(>1%? �Yes ❑ I�o Comments:_ _. ___ <br /> Can BN!D be pulled oul for inspection and maintenance ailer looseri�ng lhumb screv,? f�Yes ❑ No <br /> Is DWD locked inlo ihe proper posilion and thumb screr�tightened? kj Yes ❑tJo � <br /> Circle ihe BWD cover. ir ion c ver anciscapearna} tra(ficload bearing cover(drive surface)I access halch(building) <br /> Was property o�vner shown the localion of the installed BWD? �Yes ❑ No Commenls: <br /> Property Owner's Signalure: Date: , <br /> Inslaller's Signature� � _ Date:��/.s'' ' <br /> Rrvision: 2 1 :vionday,September 15,2014 <br /> � <br />