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�. <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: ,� <br />Date Backwater Prevention device (BWD) was insta <br />Inslallation Property Owner Name and Contact Info: <br />PropeAy Address: / % / .S� ►9'► N f.2. <br />�� <br />� z-r <br />Date this form was compieted: / Z � <br />Pre-Installation inspection Checklist: <br />All items musf 6e checked 'Yes' in orUer for a BWD fo be considered /or installafion <br />Is there a basemenl or level of the house Mat is at or near assumed sewer main elevation? D�s ❑ No <br />Are there fiztures in lhe house located below the upsUeam sewer manhole rim elevalion? �� ❑ No <br />Is the side sewer curcently UNPROTECTED ftom sewer backups (does not have a BWD installed�? ��s ❑ No <br />Site Inspectian CAecklist: <br />All items must be checked 'Yes' 6efore inspection is considered cromplete <br />Was side sewer N inspected from building to sewer main? [f�.Yes�� No Cond'rtion: L u% �-'«7— <br />Dces side sewer have at leasl 1% slope from the building to sewer main? �s ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been ident�ed and located? . es ❑ No <br />Have all property stortn drainage connedions lo tAe side sewer been idenGfied and lacated? [�'�� ❑ No <br />Has property been evaluated for drainage defiaendes with findings communicated to property owner? �'I'es ❑ No <br />Installation Detafls: <br />What lype and brand of BWD was installed at this s' (Clean Chec VW, Grinder pump, etc.): �� ac-C-' iu-�-�(C <br />Where was the,deyice installed (general descriplion, a ac map)? /�-'!3 �teK_ S�u�i .�=� <br />Was there any other sewer or storm�ainage work campleted in conjunclion wilh the BWD work? Is so please describe: _ <br />%%�2^ o _-"�— - <br />Installalion Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? es ❑ No Comments: <br />Does BWD positioning meels minimum slope requirement of>1 °h? �� ❑ No Comments: <br />Can BWD be pu�led oul far inspection and maintenance after loosening thumb screw? �� 0 No <br />Is BWD locked into the proper positio tightened? . es ❑ No <br />Circle lhe BWD cover: irrigation co er (landsca traffic load bearing cover (drive sur(ace) / access hatch (building) <br />Was property owner shown the location of the installed B D? �.VeSr� No Commenis: <br />� <br />I � <br />Pro�edy Owner's �����'.� � — Dale: � � — �_ <br />Installer s <br />Date: � Z 3 • � � `� <br />Revision: 2 ; 1 Friday, Septemher 12, 2014 <br />