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i <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Ins'.allation Company Name and CoMad Info: !9D`t P��m 6�✓�� LC- ' cR,s-LI 0 g- o t'z-3 <br /> Date Backwater Prevention device(BWD)was installed: +—I y �i 5 Date this fortn was completed: 7 — Z�- I S <br /> Installatlon Property Owner Name and Conhact Info:� er �U c h-� �s• <br /> Property Address: l °,32 IZ c uC�F-e�� � l�9'�✓e <br /> Pre-Instailation Inspectlon Checkiist; <br /> All items must be checked`Ves'in order for a 8 WD to be considered for inslallation <br /> Is there a basemeM or level of the house that is at or near assumed sewe�main elevationl�'f s ❑No <br /> Are there fodures in the house located below ihe upstream sewer manhole rim elevation?[��'es ❑No <br /> Is ihe side sewer curren0y UNPROTECTED ftom sewer 6ackups(does not have a BWD inshalled)?[}'Yes ❑No <br /> Site Inspecdon Checklist � <br /> All items must 6e checked'Yes'be(ore inspection is considered complete � <br /> Was side sewer N inspected from building lo sewer main7 [t�'es ❑No Conditlon: ��Z 1'�� ' 1�Z (�I c� � <br /> Does side sewer have at least t%siope from the building to sewer main? �s ❑ No Describe: � <br /> Have ail building sewar drain conneofions to the side sewer been identified and located? �s ❑ No ! <br /> Have all properly stoRn drainage connections to the side sewer been identified and located7 [a'1�es ❑ No i <br /> Has property been evaluated for drainage defiaencies with 6ndings communicated to proFerty owner? [�'�s ❑No <br /> Installatlon Detalls <br /> 1Nhat type and brand of BWD was installed al this sile(Clean Check BVW, Grinder pumt�. etc.): e�t��"`C�ec-� <br /> Where was ihe devia:installed(gene�al description,attach map)? g�d-e� l�� �d ��� �� Z�� � <br /> � �c�w � � <br /> Was lhere any olher sewer or storm drainage worlc completed in conjunction with lhe BWD wotk7 Is so please describe:_ <br /> ��lrr� • <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnecled from upstream of the BWD? es ❑No Comments: <br /> Does 8WD positioning meets minimum slope requir�ment of>t%? [�'res ❑No Camments: <br /> Can BWD be pulled out for inspecUon and maintenance after loosening thumb scre�+fT [�es ❑ No <br /> Is BWD locked into the proper posifion an w tlghtened? es ❑No <br /> Circle the BWD cover: irtigation cove (landscape a (fic load bearir_ .;over(drive surface)/access hatch(building) <br /> Was pmperty owner shown ihe location of the installed BWD? �s ❑No Comments: <br /> Pmperty Owne�s Signature: lC�ri--�"v`'`"�- Date: l—�7-/S <br /> Installet's Signalure:�/�i��:��_ Date: I—���5 � <br /> Revislon:2 1 Friday,Seplember 12,2014 I <br />