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� � <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> ([.�tCC �C_'��1fi i <br /> Instailation Company Name and Contact Info:�P f� ��-� ''l �.^�'l�}����c�F S"'<rY!` LL C:..l�Gi�-;."c� _,Z�1� i <br /> Date Back�vater Prevention de��ice (BWD)vras installed:�,��Dale ihis form was completed:��(� <br /> Installation Property Owner Name and Contact Info:_ �Z_�=s�-1=-�x-S� <br /> Property Address: _ � • � - - <br /> Pre•Installation Inspection Checkiist: <br /> All items.must 6e checke i'Yes'in order for a BWD to be considered for installation <br /> Is tnere z basement or level of the house that is at or near assumed sew, ;mai�elevation?�Yes ❑ No � <br /> Are there tixtures in the house located below the upstream sewer manhole rim elevation?�Yus ❑ Plo ! <br /> Is the side sewer currently UNPROTECTED from sewer backups(dnes not have a 9WD installed)? �J res ❑No � <br /> Site Inspection Checklist: <br /> All ifems must be checked 'Ves'be(ore inspection is considered complete / <br /> Was side sewer N inspected irom 5uilding to sewer main? �Yes ❑ No Condilien:__ _�i— <br /> Does side sewer have at least 1�6 slope irom the building to setver main? �Yes � No Describe: <br /> Have all building sewer drain connections to the sitle sewer been identified and located? �Yes ❑ No <br /> Have all property storm drainage connections tu lhe side sewer been idenGfied and located? �Yes ❑ No � <br /> H2s property been evaluated for drainage denciencies with findings communicated to prop2rty o�vner? �Yes ❑No i <br /> Installation Details: 1 n <br /> What type and brand of BLVD was installed at ihis site(Clean Check BWV, Grinder pump,etc.):�Pr`irY' ,"�j��.E� <br /> Where was Ihe devicz installed (general descnption,attach map)? �,����<' �r� �S ril-� <br /> � <br /> UVas there any other sewer or storm drainage work completed in conjunction with the DWD work?Is so please desc�ihe:_ I <br /> -�.1�� <br /> InsWilation Checklist: ' <br /> Are all downspouts and site drainage disconnected irom upstream of lhe BWD? �Yes ❑No Commenis: i <br /> Does BV�'D positioning meets minimum slope requirement o`>1°�0? �Yes ❑Na Commenls _ � <br /> Can BWD be pulled out for inspection and mainlenance afler loosening ihumb scre�v? j�(Yes ❑ No I <br /> Is BWD locked into Ihe pmper position and thumb screw tightened? � Yes ❑No � <br /> Circle the BWD cover. igaGon co (londscape area)I Vaffic load bearing cover(drive surtace)I access hatch(building) <br /> Was property o�vner shown the lo�ation oi the instalied BWD? [�[Yes ❑ No Comments: <br /> / , �/ / <br /> Property Owner's Sig�ature: _ Date:�E' C �___L <br /> Inslaller's Signature: Date:� S �_ <br /> Revision: � 1 Friday,Septem6er 12, 2014 <br />