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BACKWATER P�tEVENTION DEVICE FINAL <br />INSTALLa►TION CHECKLIST <br />Installation Company Name and Contact Info: ' Z- � 0 Z <br />Date Backwater Prevention device (BWD) �vas ins'alled= .- - Date this form was completed:���i�s <br />installation Properly Ovmer Name and Contact Info: iY1 1�Aei� �i+��"-LS S l� �P �S3-� S 1�/ <br />Property Address: � % r� `� ��°'`� �'� <br />Pre•Install�tion Inspection Checklist: <br />All items must be checked 'Yes' in order /or a BWD to be considered (or installation <br />Is there a basement or ievel oi the house that is at or near assumed setiver main elevation? �❑ No <br />Are lhere fixtures in the house located below Ihe upstream sewer manhole rim elevation7 es ❑ No <br />is the side sewer curcenlly UNPROTECTED from sev+er backups (dees not have a BWD inslalled)? [1�fes ❑ No <br />Sile Inspection Checklist: <br />All items must 6e checked 'Yes' 6e/ore inspection is considered complete G <br />Was side sewer TV inspected (rom building lo sewer main9 [�-1`e� � No Condition: Cow�u�-� � l <br />Does side sewer have at least 1% slope from ihe building lo sewer main? [�Yes ❑ No Describe: <br />Have all building sev.�er drain connections to the side sewer been identified and localed? �es ❑ No <br />Have all property storm drainage c�nnections to lhe side sewer been itlentified and Iocated? [��es ❑ No <br />Has prope�ty 6een evaluated for drainage deficiencies wilh findings communicated to property owner? [�'es ❑ No <br />Installation Details: �� , ��� <br />What ly�e and brand ot BWD was installed at this site (Clean Check BWV, Grinder p�mp, elc.): �-�-w <br />Where was Ihe device installed (general description, attach map)? _�' ° ��`n ' — <br />Was there any other sewer or storm drainage work o pleled in conjunction with Ihe BWD work? Is so piease describe: _ <br />� �. . _ II1.� .,. _ r..�-..� <br />Installation Checklist: <br />Are ali downspouls and site drainage disconnected from upstream of the BWD7 [��+'� � No Comments: � <br />Does BWD posilioning meets minimum slope requiremenlo(>1%? [I�`E� ❑ No Comments: <br />Can BWD be pulled out fur inspeclion and maintenance after loosening thumb screw? �a`efs ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? [�-1'e� ❑ No <br />Circle Ihe BWD cover: irrigation cover (landscape area) I iraHic load bearing cover (drive suriace)1 access hatch (building) <br />Was properly ov+ner stio�,vn Ihe lo�ation of the installed BWD? y[�f�s � No Comments: <br />Property Owner's Signafure: 1'�µ^^�- Date: �/��'� <br />Installer's Signature: � � /► Dale: ���--- <br />Revision: 2 <br />Friday, Septemher 12, 2014 <br />