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BACKW�►TER PREVENT90N DEVICE FINAL <br />�NSiALLAiIOBV CFiECKLIST <br />Installation Company �auie and Contact �nto: M'���� I��� �� ��� %1 y �( i S- ��U �-k 3� c <br />Date Backwater Prevenlion device (BWD) was installed: $�� ( S� Date this form was completed: S�' � Sr <br />Installafion Property Owner Name and Contact Info: S�� !-� IS �/�` y2r 3orr �s'4 � <br />Nroperty Address: a`� vy �zk2 � iCe./ _ <br />Pre•Installation Inspectlon Checklist: <br />All ltems must be checked 'Yes' in order for a BWD to be consldered lorinsfallation <br />Is there a hasemenl ur level oi the house that Is at or near assumed sewer main elevation? �'�t] Yes ❑ No <br />Are lhere fixfures in the house locafed below Ihe upstream sewer manhole rim elevation? j� Yes ❑ No <br />Is (he side se�ver currently UNPROTECTED from se�ver backups (does not have a BWD installad�7 �Yes ❑ Ne <br />Site Inspection Checklist: <br />All ilems must 6e checked 'Yes' before inspectfon is considered complete <br />Was sfde sewer N inspecfed from buildiny to sewer mainl Qjf Yes ❑ No Condition: ��U ICu� .�/r: ��c�' <br />Does s�ua sewer have at least 1% slopa from the building to setver main? � Yes ❑ No Descnbe: _ <br />liave all building sewer drain connecfions io the side sewer been Identif�d and located? (�Yes ❑ No <br />Have all property sform drainage connecliens to ihe sitle sewer been identified and located7 [�Yes ❑ No <br />Has property heen evaluated for drainage deficiencies with findings communicaled to property ovme�T � 1'es ❑�•:o <br />I�istallation Detaiis: <br />What type and �rand of a14'D was instalied al this site (Clean Check BWV, Gnnder pump, etc.): ��P� � �e � <br />Where was Ihe tlevice Instailed (gsneral description, atiach map)? �r-�,� c�,�-�- D� G.a..w <br />Was there any other se�ver or slorm dra;�iagg, work completed in conjunction v,�th the RVJD work? is sn plPase describo: <br />Installation Checklist: <br />Are all do�vnspouls and site drainage disconnected from upsVeam of Ihe BWD? � Yes ❑ No Commenis: <br />U�es B'JUD positioning meets minimum slope requirement of >t%? � Yes ❑ No Comments: <br />Can BWD be pulled ouf for inspection and maintenance after loosening ihmnb screw? �S] Yes ❑ No <br />Is BWD locked into the proper osihon and ihumb scre�.v tightened? � Yes ❑ No <br />Circie 1he BWD cov�cC�igafion c,�y (landscape area)1 Leffic load be�ring cover (drive suriar,a) / access hatr,h (buildiny) <br />Was properfy cwner shown lhe location of lhe inslalied OWD? �] Yes ❑ No Commenis: �__ <br />prope�iy Owners Signalure: Date: <br />insialler's Signalure: ��� � Dafe: � � �� <br />Revision: 2 1 �Qo�day, Septem6cr 15, 2014 <br />