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� <br /> ; <br /> i <br /> BAGk�WATER PREVENTION DEVICE FINAL � <br /> d INSTALLATION CHECKLIST ; <br /> 1 <br /> i <br /> i <br /> L �c. ' <br /> Insiallation Company Name and Contact Info:�� ;r�.f��:ua,- ^. : <br /> i <br /> Dale Backwater Prevention device(BWD) v�as instailed: _Date lhis form a�as completed: i <br /> Ins(allation Property Owner Name and Contact In(o: ' <br /> Property Address: <br /> i <br /> Pre-Instaliation Inspection Checklist: � <br /> All items must 6e checked'Yes'in order lor a 8WD to be considered(or inslallatron ! <br /> Is Ihere a basement or level oi the nouse Ihzt is at or r,ear assumed sewer main elevation?�]Yes C ho � <br /> Are there fixtures in the house located below Ihe upstream se�ver manhole rim elevalion7,� Yes ❑ �\�o <br /> Is the side sev,er currently UNPROTECTED from sewer b2ckups(does nol have a 9VJD installed)? (�j Yes ❑ No � <br /> Site Inspection Checklist: <br /> A!!items must be checked'Yes'before inspecfion is ccnsid=red cornplete <br /> Was side sev�er N inspected from building to sewer main7 �Yes ❑ �'o Condition: ' <br /> Does side sewer have at least 1°o slope from the building to sewer main? �Yes ❑ No Describe: � <br /> Have ail building sewer drain connections to Ihe side sewer been idenlifed a�d located? (�,Yes ❑ No ' <br /> Have ail property storm drainage connectians to the side sewer been identified and iocated7 [Y�,Yes ❑ No ' <br /> Has property been evaluated for drainage deficiencies with findings communicated to property ov:ner^ [�Yes ❑ No ; <br /> installation Details: I <br /> What type and brand of B�A�D w2s installed at this site (Clean Check 9�M�, Grinder pump, etc.): C��a v� c h e�,�- � <br /> i <br /> Wher�v�as ihe device installed(general description,atiach map)? @•t,�-�g i CQ.a h�v S£ <br /> — i <br /> I <br /> Was lhere any olher see�er or storm drainage work completed in conjunclion with the BVJD v;ork? is so please descnbe: i <br /> r.U — <br /> ; <br /> Installation Checklist: <br /> Are all do�vnspouts and site drzinage disconnecled from upslream of ihe BWD? [Yes ❑ No Commenis: ; <br /> Does f3bVD positioning meets minimum slope requiremeni of>1%7 �-Yes ❑ No Comments: ; <br /> Can BWD be pulled out for inspection and maintenance a(ter loosening thumb screw? �Yes ❑ No ' <br /> Is BWD locked into the proper posilion a ihumb screw tightened7 .�1'es ❑ No ; <br /> C:rcie the BWD cover: irrigation cov r(landscape a 1 tra�ic load be�riny cover(drive surface)I access hatch(building; ! <br /> Was prope�y o�vner shown Ihe location of the inslalled BWD? �es ❑ No Commenis: ; <br /> i <br /> Properly O�vner's Signa�ure: Date: ' <br /> Inslaller's Signalure: �(�'�x� �`LQ.,L Date: 'Z� �?�i 5 ! <br /> Revision: 2 1 Friday, September 17., 2014 <br />