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. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> t'��'"i ecen �.�/� �c� ^F 5�de � eA�, L Lc: <br /> , .. � . -c . c ; a � � - :� <br /> Installation Company Name and Conlact Info:Sr��.� � �� <br /> �� Ir �� Date ihis form v�as completA�': c� — <br /> Date Backwater Prevention device (BWDI�vas inslalle�`�^-� / a�--�, ,��� <br /> Installation Property Owner Name and Conlact Info: ' �b_-� <br /> ��- 41d�1— <br /> �n r7�� <br /> � At� - , EcPnD� � 1�)t� -C�'1��� <br /> Property Address: c� '' 0/1 <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BVJD fo be considered for inslallation <br /> Is there a basemenl or level ot the house that is at or near assumed sewer main elevalion? es ❑No <br /> Are t <br /> here fixtures in the house located beloer the upslream sewer manhole rim elevation? Yes �0 N Q5 a No <br /> Is fhe side se�ver currently UNPROTECTED irom se�ver bac kups (d o e s n o t h a v e a B W D i n s t a l l e d). <br /> Site Inspe�tion Checklist: <br /> All ifems must be checked`Yes'before inspection is considered complete <br /> Was side sewer TV inspected irom building to setiver main? "�'Yes ❑ No Condition: � i�� — <br /> Does side se���er have at Ieast 190 slope irom the building to sewer main? [�Yes ❑No Describe�_� <br /> Have ail building sewer drain conneetions to lhe side sewer been identified and located? ({�'iYes ❑No i <br /> Have all property storm drainage conneclions to the side sewer been identified and located? �er � Yes ❑No <br /> Has property been evalualed for drainage deticiencies wilh findings communicated to properly � <br /> Installation Details: a <br /> What type and brand of DWD�vas inslalletl at this site (Clean Cheek BWV, Grinder p�,C��•������ <br /> P)? �" <br /> Vdhere e+as the device inslalled(general deseription,attach ma �. P�--�-- <br /> Was ihere any other sewer or storm drainage�•+ork com leled i i conjunction�vith the �WD v�ork? Is so please describe: _ <br /> Installation Checklist: � No Comments: <br /> Are all do+�mspouts and sitc tlrainage diseonnecled from upstream of the EiWD. [�Yes ❑ <br /> Does BN'0 positioning meels minimum slope requirernent ot>1"/0? �Yes ❑ No Com senl❑s� N_---- <br /> Can BWD be pulled oul for inspection and maintenance after loosening lhumb screva? �' <br /> Is BWD lock:d inlo the���-1�aF<<+� and ihumh screv!tightened? [�'es ❑No <br /> Circle the BWD cov irrigalion cover(I ndscape area)!Iraftic Icatl hearing cover(drive surface)!access halch(building) <br /> Was property owner shovan lhe location of ihe inslalled BWD? �Yes ❑No CommeNs: <br /> Date: _ <br /> Y 3� �s <br /> Properiy Owner's Signature� ���� Daie: <br /> / <br /> InstallersSignature: -- <br /> 1 Friday,September 12, 2014 <br /> Revision:2 <br />