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� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Inslallation Company Name and Contacl Into: ` J IOt - - �� � <br />Date Backwater Prevention device (BWD) was inslalled: l l- �O- ly Date this form was completed: -u 24 -1 � <br />Owner Name and Cantact Into: I��d 1 4S�w210w �� � L�oU" <br />PropertyAddress: ��U"1 �W1V�j�� 1°NE -EV�.✓2r'"t- 1�►4 <br />Pre•InstallaHon Inspecfion Checklist: <br />AI! ifems must be checked '.Yes' in order for a BWD fo 6e considered lor installation <br />Is there a basement or level of the house Ihat is al w near assumed sewer main eievation? 'es ❑ No <br />Are ihere fixtures in the house localed below the upsiream sewer manhole rim elevation? es ❑�,�No <br />Is the side �ewer curtenlly UNPROTECTEO irom sewer backups (does not have a BWD installed)? � ves ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' belore inspection is considered com efe <br />Was side sewer N inspected from building to sewer main? es ❑ No Condition: o e r(� . <br />Does side sewer have at leasl 1°/a slope irom ihe building to sewer main? es ❑ No Gescribe: ' S_rl,�•�Y��r <br />Have all building sewer drain connections to the side sewer been ideritified and localed? �'1 s❑ No <br />Have all properly storm drainage conneclions to the side sewer been idenlified and located? es ❑ No <br />Has � roperty been evaluated for drainage deficiencies with findings communicated to property owner? es ❑ No . <br />Installallon Details: <br />What type and brand of BWD was installed al this site (Clean Check BWV, Grinder pump, etc.): ell �L- C <br />Whe��t i�alled�� e��ript� i�oo,eattach�ap) �� � 1 �v c.�-u �� � <br />wl <br />Was there an � olher sewer or storm drainage work co pleled in conjunction with ihe BWD work? Is so please describe: _ <br />N�.[,J � �,vZ�- �t h-cJ � n J ,zc,[P�d - U � � � /�!� � <br />Installation Checklist: C� �—H S ' <br />Are all downspouls and sile drainage disconnected from upslream of ihe BW ? Yes ❑ No Commenls: <br />Daes BWD positioning meets minimum slope requirement ot>1°h? es ❑ No Comments: _ <br />Can BWD be pulled out for inspection and mainlenance afler laosening lhumb screw? es ❑ No <br />Is BWD locked inlo lhe proper ositio nd thu b screw tighlened? es ❑ No <br />Circle lhe BWD co :' i n cover landsca e � 1 traffic lo�ad'Cearing cover (drive surface) I access hatch (building) <br />Was properly owner shown the location of the installed BWD? �}�es ❑ No Comments: <br />Pmpedy Owner's Signa _ Dale: �-')16�'' %��• l�l101'y <br />Installer's Signat � Date: ^��' Z`I' ��_ <br />Revision: 2 <br />friday, September 12, 2014 <br />