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� <br />� <br />BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />���..�r �,a�y�„ 36d-391- H�Si <br />InstallationCompanyNameandCo�tactlnfo:��`iZ(eqirvcir's.��� 7oeZlGti kzs-f��b-73�'s <br />fl-4 ++,n, u.s 20�5 <br />Date Backwater Prevention device (BWD) �vas inslalled: Date Ihis form was completed �— G�— �s <br />� ?-63d bv�/ l 6 ' � <br />�nstallation Prope�ly Owner Name and Contacl Info. t�'���`��N P�ery� Fa��i,�7�ust s�ar��, �„� 9�ibb <br />PropertyAddress: 2609 l�B��e���er%��.� Ede�rH� �� �}&z�i <br />Pre-Installation Inspection Checklist: <br />AII items must be checked 'Yes' in order for a BWD to be considered (or installation <br />Is there a basement or level oi the house that is at or near 2ssumed sewer main elevation? Q Yes ❑ No <br />Are there fixtures in the house tocated below the upstream sewer manhole rim elevaticr7 QK Yes ❑ No <br />Is the side sewer currenily UNPROTECTED from setiver backups (does not ha��e a B4VD installed)? � Yes ❑ ho <br />Site Inspection Checklist: <br />All items must be checked'Yes' be%re inspection is considered complete <br />VJas side sewer TV inspecled (rom building to sewer main? � Yes ❑ No Cond�tion: O IL ____ <br />Does side sewer have at least i96 slope from ihe building io sewer r�ain? � Yes ❑ P!o Describe: 2`� <br />Have all bui!ding se�ver drain connections lo the side sewer been identi��ed and located? � Yes ❑ No <br />Nave all property storm drainage connections to !he side se�ver been identified and located? � Yes ❑ No <br />Has property been evalualed for drainage defciencies e�ilh findings communicated to prnperty owner? � Yes ❑ No <br />Installation Details: <br />What type and brand of BVJD was installed at lhis site Clean Check BWV, Grinder pump, etc.): C.lea� C'l� eClt- `I {/ <br />Where was the device installed (general description, attach map)? 6:�)�� SP��e�� ���,o /dN� ��'c�. �Alr.�s scofl, <br />ro V�y I;n� tii' h> sr��e� m��� div� <br />T <br />Was there any other se�a�er or storm drainage work completed in conjunction with the BbVD �vork? Is so please describe: _ <br />Installat;on Checklist: <br />Are all downspouts and site drainage disconnected from upslream of the BVVD? � Yes ❑ No Comments: <br />Does �WD positioning meets minimum slope requirement of>1%? � Yes ❑ No Comments: <br />Can B�NG be pulled oul for inspection and mai��tgnance aRer loosening lhumb scre���? Q� Yes ❑ Wo <br />Is BWD locked into the proper <br />Circle the BWD <br />Was property owner shown <br />Property Owner's <br />installers Signature: <br />Revision: 2 <br />screw tighlened? �f Yes ❑ No <br />l traffic loao hea�ing cover (drive surfacej I access hatch (building) <br />BWD? I� Ye�l ❑ No Commenls: <br />Date: � — � � � l.�l✓ <br />Dale: ��-�" lS <br />Friday, September 12, 2014 <br />