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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> InstallaGon Company Name and Contact Inio: /��I lU ��ru.�1d�� �°���, 3f�7 —�5�7 <br /> Date Backwater Prevention device(8WD)was installed: /�//�//�/ _Date this form a�as completed: //� /� <br /> Installation Property Owner Name and Contact Info: �a-�'� � «�� � �t�'�t <br /> ProperlyAddress: 1�/�� RccckeT A✓G ��eiea � wA 9fi:�-o/ <br /> Pre�lnstallation Inspection Checklist: <br /> P;�ifems must be checked'Yes'in order(or a BWD fo 6e considered(or installation <br /> Is there a basement or level of the house ihat is at or near assumed sewer main elevalion?�Yes ❑No <br /> Are ihere fi�Aures in lhe house located below ihe upstream sewer manhole rim elevaGon?[�Yes ❑No <br /> Is the side sewer currenlly UNPROTECTED from sewer backups(does not have a BWD instailed)?�Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'6efore inspection is considered camplete <br /> Was side se�ver N inspected from building to sewer main? �Yes ❑No CondiGon: <br /> Does side sewer have at least 1%slope from the building to sewer main7 [�Yes ❑No Describe: <br /> Have all building sewer drain connections t�Ihe side sewer been identified and located? �Yes ❑No <br /> Have all property storm drainage connections to Ihe side sewer been identlfied and located? �Yes ❑No <br /> Has property been evaluated for drainage deficiencies wilh findings communicated to property owne�l �Yes ❑No <br /> InsWllation Detafls: <br /> What type and brand of BWD was inslalled at this site(Clean Check BWV,Grinder pump,etc.): ��/t� Gh tGk j�✓ <br /> Where was Ihe device installed(general descripGon,attach map)? �L,'►��n ��aG��� en <br /> ni.,^"- . .� �� <br /> Was lhere any olher se�ver or storm drainage work completed in conjunction with the BWD work?Is so please describe:_ <br /> Nc/ — <br /> Installation Checklist: <br /> Are all downspouls and site drainage disconnected from upslream of the BWD? �Yes ❑No Comments: <br /> Does BWD posilioning meels minimum slope requirement of>1%7 �Yes ❑Na Comments: <br /> i <br /> Can BWD be pulled oul for inspeclion and maintenance after loosening lhumb screw? g]Yes ❑No ! <br /> Is BWD locked into the proper position and thumb screw lightened? �Yes ❑No � <br /> Cirde the BWD cover' ngation cover pan sc rea traKc load 6earing cover(drive sur(ace)1 access hatch(building) <br /> Was properly owner shown e oca ion of ih�inslalled�WD? �Yes ❑No Commenls: <br /> l,' <br /> / II� i' i� <br /> Properly Owner's Si�nan�rP• ht�.,,�i��'/.���1'��✓ Date:J���/�/�� <br /> Installer s SignatuM- � Date:J� )��/� <br /> Revision:2 1 Friday,September 12,:014 <br />