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�� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />InsWllaGon Company Name and Conlad Inio;i�P�//a /�/t�,Q i? r�U <br />Date Back.vater Prevenlion device (BWD) was installed: ��F�' �� Date this form was completed: '�'=3 i� <br />Installalion Property Owner Name and Contact Info: C>.,i y A2.�/'Dr <br />PropertyAddress: [7� !Zu nc� <br />Pre•Installation Inspection Checklist: <br />All items must 6e checked 'Yes' in oider (or a BWD to be considered for rnsfallatron <br />Is there a basement or level of the house that is at or near assumed se�ver maio elevation? [�Yes ❑ No <br />Are there 6xlures in ihe house located belon� the upstream sewer manhole rim elevalion? [� Yes ❑ No <br />Is the side sewer currently UNPROTECTEL from sewer backups (does not have a BNJD installedj? � Yes ❑ No <br />Site Inspection Checklist: <br />Ail ifems must be checked Nes' 6efore inspecNon is considered complefe <br />Was side sewer N inspected irom building to sewer main? 1'es ❑ No Condilion: <br />Does side sewer have at least 1% slope (rom the huilding to sewer main? �Yes ❑ No Describe: <br />Have all building sewer drain connections lo the side se�.ver been idenlified and located? ,�Yes ❑ No <br />Have alt property storm drainaye ccnnec6ons to the side sexer been identified and locatedl �Yes ❑ No <br />Has property been evaluated for drainage deficiencies �vilh findings communicated to property ovme� �Yes ❑ No <br />Installation Details: <br />NJhat rype and brand of BWD was inslalled at this si� Clean Chec�.B1 , rinder pump, etc.): <br />Where v.�as the device instatled (general description, attach map)? ��../�v��r�� . i a S�,s� �7 � o F <br />Was there any other se�ver or storm drainage work completed in wnjunction with the 8WD work? Is so please describa _ <br />Inslallation Checklist: <br />Are all downspouls and site drainage disconnected (rom upslream af Ihe BWD7 �Yes ❑ No Commenis: <br />Does BWD positioning meets minimum slopc requirement o(>1°/a1 � Yes ❑ No Commenis: <br />Can 8WD he pulled out (or inspeclion and maintenance after loosening ihum6 screw? � Yes ❑ No <br />Is BWD locked �nlo lhe proper p_nsitionaqdlhumhsuE�ghtened? [�'Yes ❑ No <br />Circle the BWD co . irtigation cover (landscape area tr�Kc load bearing cover (drive surface) ! access halch (building) <br />Was property owner shown e oca ion o� Iled BWD1 (��Yes ❑ No Comments: <br />Property Owners SignaWre• l./�%��CY✓� _ Date: 3��� //S' <br />Installer's Signalur� Date: ,��/ ///,f <br />Revision: 2 1 Friday. September 12, 2014 <br />