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� <br /> ; <br /> BACKWATER PREVENTtON DEVICE FINAL <br /> INSTALLATION CHECKLIST ' <br /> � <br /> � <br /> Inslallation Company Name and Contact Info:l�lu��i� ahy �'L���i + <br /> Date Backwater Prevention device(BWD)�vas installed:•�'��N"-�o(5 Date this form t�:as completetl:2- ?S���� ; <br /> Instaliation Property Owner Namc and Contact info:(f��=e�r� � �S�e� _ � <br /> Property Address: ,���?. ru���ti ��`= <br /> Pre•Installation Inspection Checkl(st: <br /> Ali items musf be checked'Yes'in ordar for a BWD to 6e considered for installatron <br /> Is there a basement or level of the house that is?:or near assumed sewer main elevaiion? ��Yes ❑ No <br /> Are Ihere fixtures in the house located belotv the upstream sewer manhole rim elevation?�i Yes ❑No ; <br /> Is the side sewer currently UNPROTECTED(rom sewer bac:<ups(does not have a BWD inst�lled)?�Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'betore inspec6on is considered complete <br /> Was side sewer N inspected from building to s2wer main? �Yes ❑No Condition: <br /> Does side se�ner have al least 1%slope(rom lhe buiiding to sewer main? �Yes ❑ No Describe: ' <br /> Have all building se�ver drain connr,clions to the side sewer 6een identified and lorated? ��Yes ❑ No <br /> Hzve all property starm drainage connections to the sitle sewer been itlentlfied antl located? �Yes ❑No <br /> Has property been evaluated for drainage deficiencies with tindings communicated to propedy o:vner7 �'Yes ❑ No ;. <br /> Installation Detafls: ,- -•- } � <br /> lrJhat type and brand oi BWD v��as insial!ed at this site .Clean Chec B�NV, Grinder pSimp,etc.j: � � ��� -�' .� r ; <br /> ��----�+"t" <br /> UJhere aas the device installed(general descnplion,atlach map)? �j " Fl z - <br /> � <br /> l+Jas there any olher sewer or storm drainage eaork completed in conjunction with the BWD work? Is so please descri6e: /�'v i <br /> Installation Checklist: ! <br /> Are all downspnuts and site drainage tlisconnected from upstream of ihe BIND? �Yes ❑No Commenls: ; <br /> Does BWD positioning mee�s minimum slope requirementoi>1°/a? �il'es ❑No Commenis: ' <br /> Can BIND be pulled out for inspection and mainlenance after loosening thumb screw? �Yes ❑No ; <br /> Is BWD locked into the proper positio��tlwmt�cre�t�tightened? �Yes ❑No � <br /> Circle lhe BWD cover. irrigation cove (landssape a�e )I traffic load bearing cnver(drive sudace)(access hatch(building) ; <br /> V<<as property o�vner shown ihe location o(the inslalled BWD? �Yes ❑No Commenls: ' <br /> Property O�vner's Sig�at'u��re: � Date: a"���� � <br /> t��R��� �tis�.�.� �-�u��Uy�' <br /> installer'S Signature: __ _ Date: - „�- �`� <br /> ftevision: 2 1 Monday,September 15, 2014 <br /> i <br />