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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:��.r�,(� �ICo���/_ <br /> Dale Back�vater Prevenlion device (BWD)was Installetl: ��. 'Z� Date this form was completed: I Z �D <br /> Inslallalion Property Owner Name and Conlact Info: V-1�tYL'I n�1�GLu <br /> Property Address: I 10��1 Q:1 V.e.� �/� <br /> Pre-Installation Inspection Checklist: <br /> All ilems must be checked'Yes'in order for a BWD fo be considered for insfallation <br /> Is lliere a basement or level oi!he house ihaf is at or near assumed sewer main elevation7�Yes ❑ No <br /> Are Ihe;e fixlures in the house located beiow the upsiream sewer manhole rim elevation?�J Yes ❑ No <br /> Is ihe side sewer currently UNPROTECTED from sewer backups (does not have a BWD i�stalled)1 � Yes ❑ No <br /> Site Inspection Checklist: <br /> All ilerns must 6e checked 'Yes'before inspection is considered complete <br /> lNaa side sewer TV inspected from building lo sewer main? �j Yes ❑No :.ondition: <br /> Does side sewer have at least 1%slope from the building to sewer main7 j�Yes ❑ No Describe: <br /> Have all building se�ver drain conneclions to the side sewer been identified and located? �`Yes ❑ No <br /> Have all property storm drainage connections to lhe side sev�er been idenlified antl located7 (�Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with fintlings communicafed fo property owner7 �Yes ❑No � <br /> Installation Delails• <br /> Whal type and brand ot �'aJD aas installed at lhis site(Clean Check BWV, Grinder pwnp,etc.):CI,QC�n (;��.��'� IL ' <br /> Nlhere was ihe device inslalled(general description, atiach map)? �n � �n�,�� � <br /> � - <br /> VJas there any other sewer or storm drainage�vork completed in conjunction�vith Ihe BWD v�ork? Is so please describe: <br /> �� — <br /> Inslallation Checklist: A <br /> . r <br /> Flre all downspouls and site drainage disconnecled rrom upslream of Ihe DWD? �C]Yes ❑No CommeNs: <br /> Does BWD posilioning meels minimum slope requlrement of>1%? [�.Yes ❑ No Commenls: <br /> Can BWD be pulled oul for Inspection and maintenance afler loosening Ihumb screwl �]Yes ❑ No � <br /> Is BWD locked into�the prop�positioR�enEl-lbumh s�rew tighfened? �] Yes ❑No � <br /> Circle the BWD co� r: irri afion cover Ilandscave are�/traftic load bearing cever(drive surface)1 access hatch(building) <br /> Was property owner shown ihe location of Ihe installed BWD? [�]Yes ❑No Com�nents: <br /> Property Owner's Signatur@� Dale: f� .� <br /> installer'sSignalure�.(��'�; .�C��C-�� -( Dale: �� '�l�ll`1 <br /> Revlsion:2 1 Friday, September 12, 2014 <br />