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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> �fi�cc�n sc;(+ �U �r �.��de sc;�Lz�� L LCG <br /> --r rn �..,,. ii�� •�. ni-C�5%�nii'Y�lc -�4i �)'�G�.. ��j,S`.:� <br /> Installation Company Name and Contact info:.�� �F �� .� �-�� • T � <br /> Date Backm�ater Prevention device(BWD)�vas inslalled:-��s�.�,�—Date ihis form ti+�as completed: � ^ ^- <br /> K �rn—�� � 3¢¢ - 4�a.� <br /> Inslallalion Property O��+ner Name and Contact In(o: 'P�s✓L��'� <br /> PropertyAddress:��� �I � �'� ��� �� <br /> Pre•Installation Inspection Checklist: <br /> All ifems must be checked 'Yes'in order for a BWD to 6e conside,r-d for installation <br /> Is there a basement or level oi the house thal is at or near assumed sewer main elevation?�'es ❑ No <br /> Are there fixtures in lhe house located below the upstream sewer manhole rim elevation? �''Yes ❑ No <br /> Is ihe side sewer currently UNPROTECTED from se�ver backups(does not have a BWD inslalletl)? [�'es ❑No <br /> Site Inspection Checklist: <br /> AII items must bE checked'Yes'6efore inspection is considered complete <br /> VJas side sewer TV inspected trom building lo sewer main? �Yes ❑ No Condition:_ <br /> Does side sewer have al Ieast 1%siope from the buiiding to sewer main? [�Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side se�ver been identified and located? [�Yes ❑No <br /> Have all property storm drainage conneclions to the side se�ver been identified and located? �Yes ❑ No <br /> Has property been evaluated for drainaga deficiencies with findings communicaled to property owne(? �1'es ❑No <br /> Installation Details: �� <br /> What lype and brand of BWD a�as instalied at this site (Clean Check BL�VV,Grinder pump,etc.)� <br /> Where was ihe device installed (general description,attach map)? <br /> � �l �1�:�N- <br /> lNas ihere i�ther sev�er�storm drainage wnrk completed in con�ih th�DWD�`1o�k�so P�e�ase�d-e�scribe:—� <br /> ,�n <br /> _�__�51�,i�t°u��_Dd.1?- d���yylc.�.vtn.��tct-w-- <br /> Installation Checklist: <br /> Are all do�vnspouts and sile drainage disconnected from upslream oi the �WD? [�Yes ❑ No Comments:__. <br /> Does BWD positioning meeis minimum sl,�pe requiremen[o(>1%7 �Yes [] No Comments_ __ <br /> Can BWD be pulled out for inspection arid maintenance atter loosening Ihumb scre�v? �„r�Pes ❑ No <br /> i <br /> Is BWD locked iNo the coryerpositioo-a d thumb screw lightened? �es ❑ No <br /> Circle the BWD c er, irrigation co �p scape area)I traffic load bearing cover(drive surfaee)I access halch(building) <br /> lNas property owner s own lhe location of Ihe installed BWD? �Yes ❑ No Comments: <br /> � � q, �� <br /> Property O�vner's Signature� � i� � � Date: — <br /> Inslaller's Siynature: � Date: <br /> Revisian:� 1 Friday, September 12,2014 <br />