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BACKWATER PREVENTION DEVICE FINAL <br /> I�fSTALLATION CHECKLIST <br /> Installation Company Name and Conlact Inio: �7Yoi/ri �/.o,�r R�.,.� ��/2s� �&7 —«7 <br /> Date Backwater Prevention device(BWD)was installed:��Date this form was complefed: <br /> lnstailaGon Property Owner Name and Contaet In(o: r+��r�r G�a wG�r �/7�5�3�/� —3 7�fl <br /> Pro,�erty Address: iG�S� i2ock e f e//r/ Fv e �r�+ wA 9frz�/ <br /> Prc-t��stali�i�on Inspection Checklist: ( <br /> All items n�• be c,hesked'Yes'in order for a BWD fo 6e considered(or;nsfallafion <br /> Is there a�: ,ament or level oi the house that is at or near assumed sewe:main elevation? �Yes ❑No � <br /> � <br /> Are there���x;�res in ihe house located below the upstream sewer manhole rim elevafion?(�,Yes ❑No <br /> Is,h?side:,ewer currenUy UNPRGlECTED from se,ver backups(does not have a 8WD installed)?{��i c� ❑No <br /> Site Inspe� �•,��Checklist: <br /> All items musl be checked'Yes'6e(ore inspection is considered complete <br /> Was side sewer N inspected from building to sewer main? [d�'es ❑No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? �Yes ❑No Describe: <br /> Have all building sewer drain connections to lhe side sewer been identified and localed? �Yes ❑No 1 <br /> Have all property storm drainage connections to the side sewer been identified and located? {�Yes ❑ No I <br /> Has properly been evaluated for drainage deficiencies with findings communicated to properly owner? �Yes ❑No � <br /> Installation Details: <br /> Whal type and brand of BWD was installed at Ihis site(Clean Check BWV,Grinder pump,etc.): �/C�,n :%� ec.� <br /> Where was lhe device installed(general description, attach map)? ,1,� -�-����n �it� n/�✓ i��n�-i <br /> � ' r� I <br /> Was there any olher sewer or storm drainage work completed in conjunction with lhe BWD work?Is so please descnbe:_ <br /> i✓U <br /> Installation Checklist: � <br /> Are all downspouts and sile drainage disconnected from upslream of lhe BWD? ❑Yes �No Comments rlu,r+-�Ay p��1�n � <br /> Does BWD posi6oning meels minimum stope requirement of>1%? [Q�Yes ❑ No Commen;..: � <br /> Can BWU be pulled oul for inspecGon and maintenance after loosening thumb screw? �Yes ❑No � <br /> Is BWD locked into the proper position and thumb sae�v tightened? �Yes ❑No � <br /> Circle the BWD co .urigaUon cover(an scape area ! a(fic load bearing cover(drive surface)I access hatch (building) <br /> Was property owner shown ihe Iccation of the instalied BWD? j�Yes ❑No Comments: <br /> .� <br /> Property Owners Signatt . ��G'��/ Date:_ /��/.2����� <br /> Installels Signalur Date: /�. /�.?�/�/ <br /> Revision:2 1 Friday, September 12.2014 <br />