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BACKWATER PREVENTION DEVICE FINAL <br />� INSTALLATION CHECKLIST <br />Inslallation Company Name and Contact Inio: ��}El.l,i� ' `�� ��3y�U <br />� <br />Dale 8ackwater Prevention device (BWD) v�as installed;�� Dale lhis (orm was completed: / /. <br />Installation Property O�r+ner Name and Contaet Infa ��J �,V r 1 i��GC� <br />Property Address: %�(U �I�17JI�Il-- A-tl F <br />Pre-Installation Inspection Checklist: <br />AN items musl be checked '1'es'rn order (or a BWD to be considered for installation <br />Is ihere a basemenl or level of ihe house that is at or near assumed sewer main elevation�Yes ❑ No <br />Are there f>:tures in the house located belov� the upstream setiver manhcle rim elevation? Yes ❑ No <br />Is ihe side se�r:er currently UNPROTECTED irom se�t�er backups (does not have a B'ND installed)?� Yes ❑ No <br />5ite Inspection Checklist: <br />Afl items must be checked 'Yes' be%re inspection is considered complete <br />t1'as side se�:�er TV inspected from buitding to sen�er main? � Yes ❑ No Condilion: <br />Does side se�.ver have at Ieast 1% slope from lhe building to sev:�er main? � Yes ❑ No Describe: <br />Have all building se�ver drain conne�tions to the side sev+er been identified and located? � Yes ❑ No <br />Have ali property storm drainage connections to !he side sewer been �denti(ied and located? �Yes ❑ No <br />Has property been evaluated for drainage defieiencies v�ilh findings communicated lo property owner? �Yes ❑ No <br />Installation Details: <br />What type and brand of 841�D ���as installed at Ihis sile (Clean Check BWV, Grinder pump, elc.) � <br />Where was ihe d vice installed (gereral description, attach map)?� ii �� e � <br />� Lk=L�t1 U <br />Was there any other se�ver or storm drainag�.work completed in conjunction with ihe DW4 w.ork? Is so please describe: _ <br />Installation Checklist: <br />Aie all downspouts and site drainage disconnecled (rom upslream of ihe BWD? � Yes ❑ No Comments: <br />Docs B�VD positioning meets minimum slope requirement o(>1%? [�Yes ❑ No Commenls: <br />Can 914�D be pulled out for insper.tion and maintenance after loosening thumb screw? �Yes ❑ No <br />Is 6lND Iecked in(o the proper position and thumb screvr tightened? /�Yes ❑ No <br />/ <br />Circle Ihe BVdD co��er: irrigalion cover (landscape area) I irafiic load bearing cover (drive surface) I access hatch (building) <br />V��as property ovrner sho�,vn the location o( the installed BVJD? �Yes ❑ No Commenls: <br />Property O�vner's Signafure: � Dale: �3 ` I I—' I 5 <br />Installer'sSignature: �C�-(� Date:r�' //�/Sr <br />Revision: 2 1 Friday, September 12, 2014 <br />