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. . - - . �� ,. - . . . � . . r-.y,'_-:ti '-. ,i• - - <br /> . r <br /> ', ' <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION 'CHECKLIST <br /> � <br /> Installation Company Name and Contacl Info:���//a �/�..��1 <br /> Date Backwater Prevention device(BWD)was,installed: 3/�!�/.� Date this form was completed: 3 �-� <br /> Installation Property Owner Name and Contect Info: ���-� S !%nl,t�S <br /> PrcpertyAddress: 2y,[/ /��ne �� `` � <br /> Pre•Installation Inspection Checklist: ''� , <br /> y•. <br /> All items must be checked'Yes'in order lor a BWD fo be cbnsidered(or insfallafion <br /> 1 .. <br /> Is there a basement or level of the house that is at o�near assumed sewer main elevalion� Yes ❑No <br /> Are lhere fixtures in the house located 6elow the upslream sewer manhole rim elevation7 Yes 0 No. ; . <br /> Is the side sewer currentiy UNPROTECTED from sewer 6ackups(does nol have a BUJD installed)7,�:Ye:❑ No <br /> Site Inspectlon Checklist: `•� �" <br /> ,. + ,.�. <br /> A!1 ifems must 6e checked'Yes'befae ins ection is consiaered com lete . ' ''��� " `� <br /> P P ,..„ . 2"=."�t:�.F' <br /> Was sioe sewer N inspected from building to sewer main?"[�Yes ❑No,Condition:±' f=� ' <br /> Does side sewer have at least t%slope from Ihe building to sewer main? �Yes Q No Oescribe:f•i <br /> Have all building sewer drain connections to lhe side sewer been identified and located7 r,/]Yes � No <br /> � <br /> Have all property slorm drainage canneclions lo the side sewer been identif d and lacated7� ,�[]Yes ❑No :�' ';.� <br /> Has property been evaluated(or drainage deficiencies�vith findings communieated to property owner? Yes`' �'No <br /> P� <br /> Installatlon Detaiis: • ' ' <br /> What type and brand o(BWD was installed at this site &I n Chetk B ,Grinder pump,elc.): <br /> Where was Ihe device installed (general description,attach map)7 13��/� ��aiA ` <br /> y / ♦ <br /> �1 ^T, <br /> Was ihere any other seiver or storm drainage work completed in conjunction wilh the BWD work?Is so please describe:_ <br /> n,C� . <br /> �T.�.,,,� . <br /> .. '`Installation Checklist: ' <br /> t`.r�.�., , <br /> • � Are all downspouls and sile drainage disconnected fram upstream of Ihe B�ND9 �Yes ❑ No Comments: <br /> Does 8WD posifioning meels minimum slope requirement of>1%7 �Yes ❑ No Commenis: <br /> Can BWD be pulled out(or inspection and maintenance afler loosening ihumb screw? �Yes ❑No <br /> Is BWD locked into the proper position and ihumb screw tightened? [�Yes ❑No <br /> Circle ihe BWD cov . irtigallon cover(lands�area 1 traKe�oad bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown!he location of lhe inslalled BWD7 Q]Yes ❑No Comments: <br /> / <br /> Property Own:rs Signa ure� Date: 3-�i- I � <br /> Inslallers Signal� � — Date: .3�4��s <br /> �__ -.., <br /> Reoizion:2 1 Friday,September 12,2014 <br />