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BACKWATER PREVENTION DEViCE FINAL <br />lNSTALLATION CHECKLIST <br />I�slallaGon Company Name anu Contad lnfo: !/�i!/� P'/a �d � � s S� ��� ! <br />Date Backwaler Preven6on device (BWD) was installed: =�/ �/i� Date lhis fortn was completed: �Z�� �� <br />Installation Property Owner Name and Contact Inio: GG�vG.• % Grr/b `�� h Ghti rGI� <br />PropertyAddress: �53� /ZGGIGG�F-F//P� <br />Pre•Installation Inspec0on Checklist: <br />AII iterns must 6e checked'Yes' in order (or a BWD to 6e considered for instalfation <br />Is there a 6asement or level of the house that is at or �ear assumed sewer main ele��alion7 � Yes ❑ No <br />Are there fixtures in ihe house located below Ihe upsUeam sewer manhole rim ele'daGon7 � Ye� ❑ No <br />Is the side sewer curtently UNPROTECTED irom sewer tackups (does not have a BWD installed)? �Yes ❑ No <br />Site Inspeetlon Checkllst: <br />Alf ifems must be checked 'Yes' 6efore inspecfion is considered complefe <br />Was side sewer N inspected irom building to sewer mainl � Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer mai�? Yes ❑ No Deseribe: <br />Have all building sewer drain �: �nections lo the side sewer been IdentlSe and located7 �] Yes ❑ No <br />Have all property storm drainage conneclions to lhe side sewer been idenfified and loca�d� �Yes <br />Has property been evaluated for drainage deficiencies �vith findings commu�icated lo property owner? <br />Instaliation DaGlls: <br />What type end brand oi BWD was installed at this ean Check B , Grinder pump, etc.): <br />Where was the device installed (general description, a c map)? Lcrnpr � 1�' <br />❑ No <br />� Yes ❑ No <br />Was there ny olher sewer or storm drainage work completed in conjunction with Ihe 8WD work? Is so pleasa desc�be: _ <br />NO <br />Inslallation Checklist: <br />Are ali downspouls and site drainage disconnected from upstream of the BWD7 �Yes ❑ No Commenls: <br />Does BWD posi�oning meels minimum slope requirement of>1 °/a7 � Yes ❑ No Comments: <br />Can BWD be pulled oul for inspec0on and maintenance aRer loosening thumb screw7 � Yes ❑ No <br />Is BWD locked into the proper posjlionaa�{humb-s� ew lightened? ,�] Yes ❑ No <br />Circle the BWD covertm�_ q on coyer_(landscape-area Vaffic load beanng cover (drive sudace) I access halch (building) <br />Was property owner shown lhe location ot the installed BWD7 � Yes ❑ No Commenls: <br />Property Owners SignaW • � l , Date: ��� ��s� <br />Installels Signalu : - ' Date: ��y���� <br />Revision: 2 <br />Friday, September 12, 2014 <br />