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i <br /> � <br /> ; <br /> BACKWATER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKLIST � <br /> i <br /> i <br /> 1 <br /> Inslallation Company Name and Contacl Info: ��n���� �'���������ti� --- ' <br /> Date BacMvater Prevention device(BWD)tvas inslalled: 5-" -� ,Date this form was completed: S-.ZR -�S � <br /> Installation Propeity Owner ldame and Contad Info: 1>nnalc�. S1�c,L•�-cs `t <br /> Property Address: �-'�� � i�c-(�.11 e.- ra.,�' � <br /> Pre-Inslallation Inspection Cher,klfst: � <br /> All items must be checked'Yes'in order for a BWD(o be considered(or installation • <br /> Is ihere a basement or level of lhe house that is al or near assumed sewer main elevaUon? [�f Yes ❑No ! <br /> Are there fi�ures in the house located below ihe upstream sewer manhole rim elevalion?[]Yes ❑ No ! <br /> i <br /> Is the side sewer curtently UNPROTECTED from sev+er backups (does not have a BWD Installed)?�]Yes ❑No i <br /> ! <br /> Site Inspeetlon Checklist, ' <br /> � <br /> All items must be chocked'Yes'6efore inspecfion is considered complete i <br /> Was side sewer N inspecfed trom 6uilding to se�ver main? [�]Yes ❑ No Conditicn: � <br /> Does side sewer have at least 1%slope from the building to sewer main? [�Yes ❑ No Describe: : <br /> Have all building sewer draln connections to the side sewer been identi6ed and located9 [�Yes ❑ No ! <br /> Have all property storm drainage connections to ihe side sewer been identified and locateti? ��Yes ❑No <br /> Has properly been evaluated �or drainage deficiencies wilh findings wmmunicated to prooerry ovmer? �]Yes ❑ No ; <br /> Installation Details: ��—'�l ; <br /> � VJhat type and brand of BWD was installed at this siie(.�an Check BNN, Grinder pump,etc.): � <br /> ��— <br /> Where vaas lhe device installed(general description,at;ach map)? •- �� � �l ac � r y�J_E f7� ,A✓14L,�,��� ; <br /> �f,nL+1�N) �-�l�c k c,� ,-�'I . I,cn4`�e � <br /> Was lherc :.ny other sewer or stoim drainage work compleled'+n conjunction with the BN�D�vork?Is so please describe:, i <br /> ,� U ; <br /> installation Checkiist: � <br /> Are all dovmspouts and site drainage disconnected from��pstream of the BWD? �]Yes ❑ No Commenis: � <br /> Does BWD positioning meels minimum slope requirement oi>1%? �]Yes ❑No Comments: ; <br /> Can 84�'D be pulied out(or inspection and mainfonance afler looseniny Ihumb scre�v7 �]Yes ❑No � <br /> Is BWD locked into Ihe proper po;ition and.lhum�_screw lightened? [�Yes ❑ No ` <br /> Circle ihe BWD cove :imgalior.cciver(landscape area)1 tralfic�oad bearing cover(drive surface)1 access halch(building) ; <br /> �1_ <br /> Was property owner shown�e Irn;ation o(the instalfe�D? Q]Yes ❑ No Commenis: f <br /> ; <br /> Property O�vners Signature:� � Date:_ i <br /> � ✓ . <br /> Installers Signature: � Date: � - a.X � �5 � <br /> Revision:2 � 1 Friday,September 12,2014 � <br />