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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKL.IST <br /> �r-i u-�n ��+ <<� �r ��de � C.��, L LG <br /> InstallaUon Company Name 2nd CoNact info:�,� ���' �� '��'��5�l�n i✓rl� -� �;a!)n-��)sC� <br /> Dale Backwafer Prevention devic��(BWD)�vas installed: 1.5 Date this form was completed:�� <br /> Installation Propedy O�.vner Name and Contact Info: �h�_��_���� � �'✓!L_.!-Y-h' <br /> Property Address: �'�S -� 7� ' ����� <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD to be consideied for installation <br /> Is there a basement or level of ihe house that is at or near assumed sewer main elevation? �Yes ❑ No <br /> Are there fixtures in ihe house located below lhe upstream sewer manhole rim elevation?[�Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does nol have a BWD insfalled)7 [�es ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked'Yes'hefore inspection is considered complete / <br /> Was side sewer TV inspecled irom building to sewer main? �l'es ❑ No Condilion: ��7��Y <br /> Does side se���er have at least 1%slope irom the building to sewer main? (�'es ❑ No Describe: <br /> Have ail building sewer drain connections to the side sevrer been identified and located? '�'Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? �'es ❑ No <br /> Has property been evaluated tor drainage deficiencies with 6ndings communica�ed to property o�vner? �Yes ❑No <br /> Installalion Details: <br /> What type and brznd of BWD�vas installed at this site(Clean Check BWV, Grinder pump,etc.): l - <br /> Where was Ihe device installed(general description,attach map)? �i�P �d�"!dr�4Qr�����I- <br /> Was there any other sev�er or storm drainage work completed in�nj�n with ihe E3WD�vork? Is so piease describe:_ <br /> � <br /> Installallon Checklist: � <br /> Are all downspouts and site drainage disconnected irom upstream of the BWD? �'es ❑No Comments: <br /> Does BIND posilioning meets minimum slope requirement of>1%? �Yes ❑No Comments:_ <br /> Can BWD be pulled out for inspection and maintenance after loosening Ihumb scre�v? [�'es ❑No <br /> Is BWD locked into the �aperpositioma d thumb screw tightened? �}'Yes ❑ Na <br /> Circte the BWD cov r.irrigation cover(I dscape area)1lraffic load bearing cover(drive suriace)f access hatch(buildiny) <br /> Was properiy owner s wn the ca ion of ihe installed BWD? I�Yes ❑ No Comments: <br /> � ��✓ T i �� <br /> Property Owners Signature: • _ -- � Date: <br /> Installer'sSignalure: ✓�� Date: ///s / <br /> T`— <br /> Revision:2 1 Friday,September 12,2014 <br />