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i <br /> ! <br /> , <br /> BACKWATER PREV'ENTION DEi/ICE FtNAL � <br /> INSTALLATION CHECKLIST j <br /> I <br /> • _ I <br /> � <br /> Installation Company Name and Contact Info: �'��� PL�M a��c�, (.�C ,�b(o 4C(n-O`t 2 i i <br /> � <br /> Dale Back+vater Prevention device (BWD)�vas installed:3 �-� �S Date this form�vas compleled: i <br /> Installation Froperty Owner Name and Contacl fnio: Y��L�o�r� IMo S�S i <br /> PropertyAddress: �-2\`� P—oc��F�LLc.� hds (;�(s�L•-rt ���a . i�b'2o i � <br /> � <br /> Pre•Installation Inspection Checkiist: ! <br /> All items musf be checked'Yes'in order for a 8WD to 6e considered tor rnstaliation ` <br /> is there a basement or level of the ho�se ihat is at or near assumed sewer main elevafion?0'Yes ❑No . <br /> Are there fi�ures in the house located below ihe ups!�eam se�aer manhole rim elevalion?�l'es ❑ No 's <br /> Is the side setver currenlly UNPROTECTED from sewer backups (does not have a B4VD installed�?.e Yes ❑�o i <br /> Site Inspection Checklist: ; <br /> AA items must be checked'Yes'belnre inspeciion rs considered complete � <br /> Was side seefer N inspected(rom 6uilding to se�ver main7 ,�'es ❑No Condition: �G c5 C> ; <br /> Does side sewer have at Ieast 1°h slope from the building to sewer main? �'Yes ❑No Describe: � <br /> Have all building se�ver drain connections to the side sevier been identified and located? 0"4es ❑No <br /> Have all property storm drainage connections to the side sewer been idenfifietl and located? �5`es ❑ No � <br /> Has property been evaluated for drainage deficiencies��aith findings communicated lo property ov+ner? ,�]Yes ❑ No ; <br /> ; <br /> Installation Details: <br /> N'hat rype and brand of BWD tvas installed at this sile(Clean Check BWV, Grinder pump, etcJ: CC�� CN��-� ; <br /> Where was the device installed(general descriptio , attach map � <br /> 1Nas there any other sewer or slarm drainage work completed in conjuncfion with the BWD work?fs so please describe:_ � <br /> � <br /> I <br /> Installation Checklist: <br /> Are all do�vnspouts and site drainage disconnected from upstream oi the BWD? �es ❑ No Comments � <br /> � <br /> Does BWD positioning meels minimum siope requirement ot>t%7 []Yes ❑No Comments: ; <br /> Can BWD be puiled out for inspection and maintenance a(ter loosening thumb scre�v? .�"Yes ❑No ' <br /> Is BL4'D locked inlo the proper position and thum6 screw tightened? eYes ❑ No <br /> Cirde the BWD cover.irrigalion cover(landscape area)1 traifc ioad bearing cover(drive surtace)I ac�ess halch (building) <br /> N'as property ovmer shotit�n tlie I c � (t ' stailed BWD? �Yes 0 No Comments: <br /> � <br /> Property Owner's Signature: Date: � � �� � <br /> InstallersSignature: '� � Date: 3��7�1,r � <br /> Revision: 2 1 Tuesday,September 16, 2�14 ! <br /> � <br /> i <br /> t <br />