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� BACKWATER PREVENTION nEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> + I�dlu� �IH� �P�� �06 <br /> Installation Company Name and Contact Info: �Q� y�s' y�93 <br /> Date 8ac�cwater PrevenGon device(BWD)was installed: `��' ��y Date this form was completed: �� �� ' ��� <br /> Installation Property Owner Name and Contact In1fo:S�eU2� wll�lnfe� �y�� 8�' z9�'� <br /> Properly Address: �a�� Y �NQ� ST . �UQ ,(,t)/4 <br /> Pre•Installation Inspection Checklist: <br /> All ifems must 6e checked'Yes'in order for a BWD to be considered lor insfallation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?�Yes ❑No <br /> Are there fixtures in the house located below the upsheam sewer manhole rim elevation?�Yes ❑ No <br /> fs the side sewer currently UNPROTECTEb from sewer backups(does not have a BWD installed)?�Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'6e(ore inspection is considered complefe <br /> Was side sewer N inspected from building to sewer main? �Yes ❑ No Condition:�� <br /> Does side sewer have at leasl t°k siope from the building to sewer main? �Yes ❑No Describe:�t <br /> Have all building sewer drain connections to the side sew�er been identified and located? �Yes ❑No <br /> Have all properiy stortn drainage connections to the side sewer been identified and located? �Yes ❑No <br /> Has property been evatuated for drainage deficiencies with findings communicaled to property owner? �Yes ❑ No <br /> Installation Details: �`��5�I <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump, etc.): CaN C�t e'ck <br /> Where was the device installed(general description,altach map)? �� � �+ou.� Mli7 R t�°`c���� <br /> Was there any other sewer or slorm drainage work completed in conjunction with itie BWD work?Is so please describe:_ <br /> Installation Checkltst: <br /> Are all downspouts and site drainage disconnected from upslream of Ihe BWD? �Yes ❑ No Comments: <br /> Does BWD posiGoning meels minimum slope requirement of>1%? �Yes ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? �Yes ❑IVo� ' <br /> Is BWD locked into the proper siti b screw tightened? �Yes ❑ No <br /> Cirde the BWD cove . irtigation cover(landscape�re )I traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown ihe location of the i�stalled BWD? �Yes ❑No Comments: <br /> Property OH�ner s Signature: Date: <br /> Installer's Signature:�4. -�^/t'� Date: 1 �' '� �I � ��� <br /> � <br /> Revision:2 1 Monday,Septemher 15, 2014 <br />