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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:_s�/!i �/u,ni?��na Ilr;� 3Sr7 •��507 <br /> Date Backwater Prevention device(E�WD)was I,istalled:__� // / Date this fortn was completed: / � <br /> Installation Property Owner Name a;id Conlact Infc �i��Jor M�,r��„eZ �Dan;�/ ✓olKei � �i �yjf <br /> Properry Address:Ql3 �Zr���P fe�lel'_�v� �ve�e�� w� S'Sr �v/ 7i3 �'�''`r <br /> Pre•Installation Inspe�?!on Checklist: <br /> All items must be checked'Yes'in order for a�WD to be considered lor insfaflalion <br /> Is ihere a hasement or level of the house that is at or near assumed sewer main elevation?�Yes ❑No <br /> Are ihere fixlures in the house iocated below lhe upsiream sewer manhole rim elevation7�`ea ❑No <br /> Is the side sewer currenUy UNPROTECTED(rom sewer backups(does not have a BWD installed)?���s ❑No <br /> Site Inspectlon Checklist: <br /> All items must 5e checked'Yes'beforo inspectron is considered complefe <br /> Was side sewer N inspected from building to sewer i�.�in? (�Yes ❑ No Condition: �Yc�� <br /> Does side sewer have at least 1%slope from 1he building to sewer main7 �,Yes ❑No Describe: //2 i''•'� �''1" <br /> Have all building sewer drain connections lo;he side sewer been iden6fied and locatedl �1 Yes ❑ No <br /> Have all proper�y storm drainage connec:ions lo ihe side sewer been identified and located7 �Yes ❑No <br /> Has property been evaluated for drainaga deficiencies wilh findings communicaled to property owner7 �f Yes ❑ No <br /> Installation Details: <br /> What type and brand oi BWD was inslalled at this site(Clean Check BNN, Grinder pump, etc.): /1 Pi+n /,h CG�, <br /> Where was lhe device instailed(general description,atlach map)T ���u��n F�c�n� �c+�sttR <br /> J <br /> �- �- -��^� .voMh �/n�r o� htiuSG I <br /> i <br /> Was there any other sewer or storm drainage work completed in canjunction with the BWD wo�k?Is so please describe:_ I <br /> �� <br /> Installalion Checklist: � <br /> Are all downspouls and site drainage disconnecled from upsire3m o(the BWD7 �Yes ❑No Comments: I <br /> Does BWD posilioning meets minimum slope reyuiremenl ot' I%? �Yes ❑ No Comments: � <br /> Can BWD be pulled out tor inspeclion and ine�r;�nance after loosening lhumb screN? �f Yes ❑ No <br /> Is BWD locked into the propei pes;tion and Ihumb screw tighfened7 [�Yes ❑No <br /> Circle the BWD cover 'r ation cova� scape area hattic load bearing cover(drive suriace)I access hatch(building) <br /> Was property otvner shown e or:,uim o taHC�BWD7 ❑Yes (�No Comments: v� W N� on <br /> f � S�r� �/eir ••� vn/y <br /> Properly Owner's Signalure: Date:_/ 2/Z9�i� <br /> Installer's Siynalur - Date: �2f�_�/ <br /> Revisian: 2 1 Friday,September 12,2014 <br />