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�'A►', <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />• I � �-� <br />Date Backwaler Prevenlion device (BWD) �vas installed: `�L � L' bate ihis form was completed: ,�* -`—� z�(,� <br />Instailation Property Ovmer Name and Contact Info: ____ j� /, �/ �r 4_ L�.:�- <br />Property Address: 2 G � ( .f <�i.-y.,, <br />� �� <br />N.��[.�` I <br />Pre•Installation Inspection Checklist: <br />All ifems must 6e checked 'Yes' in order for a BWD to be considered lor installaGon <br />Is there a basement or level o( the house that is at or near assumed setiver main elevation? 'i Yes ❑ No <br />Are there fixtures in the house loeated below the upstrearn sev�er manhole rim elevatio�? �] Yes ❑ No <br />Is the side sewer currenUy UNPROTECTED from se�aer backups (does not ha��e a BVt�D installed)? � Yes ❑ No <br />Site Inspection Checklist: <br />All items irust be checked 'Yes' be(ore inspection is consrdered compfete <br />4Vas side se�ver TV inspected from building to see�er main? � Yes ❑ No Condilion: <br />Does side sewer have at least 1% slope irom ihe building to sevrer main? � Yes ❑ No Describe: <br />Ha��e all builtling sewer drain connecbons to the side se�ver been identifietl and Iccated? � Yes ❑ No <br />Have all property slorm drainage cornections to the side sewer been ideniified and located? .�� Yes ❑ No <br />Has property been evaluated for dra�nage deficiencies with fndings communicated lo property owner? ['�] Yes ❑ No <br />Installation Detaiis: � <br />INhal lype and brand of BWD was installed at this site (S;! ne� Chec,�1 1L�6rinder pump, eic.): <br />�— � <br />VVhere was the device instatled (general description, attach map)? J7_ - y�_�� k! c� .� ` <br />Was there any other sewer or storm tlrainage work wmpleted in conjunction with the BWD work? Is so piease describe:' "` <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? � Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement o(>1%? �-Yes ❑ No Comments: _ <br />Can BWD be pulled out (or inspe�tion and main!enance a(tc : loosening thumb screw? � Yes ❑ No <br />Is BWD Iccked inlo lhe proper position and lhumb screw tightened? �] Yes ❑ No <br />Circle Ihe 841+D cover: irrigation cover (landscape area) / traffic load bearing cover (drive sur(ace)/ access hatch (building) <br />Was propery oevner shown the location ol lhe installed BVI�D? [}Kes ❑ No <br />Properly Owner's Signature: <br />Comments: <br />�ate: <br />Installer's Signature: _�` � Dale: <br />! <br />Revision: 2 � 1` Friday, Septem6er 12, 2014 <br />