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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> InstallaGon Company Name and Conlad Info:f1l�//U �/a n d�n c �/Z S? 3 7-- /SG] <br /> Date BackNater Prevention device(BWD)was installed: /2/3�/i�/ Date this form was completed: iL �� <br /> Installation Property Owner Name and Conlact Info: f1oSc-,-,a;v l,asl4�n� ( .�� �S 7fs�i�, <br /> PropertyAddress: /�/.��. Ru��E�i �vvr�-N' c�.� J���/ y <br /> Pre�lnstallation Inspection Checklist; <br /> All items must be checked'Yes'in order fora BWD to be considered tor insfallaGon <br /> Is there a basement or level of the house thal is at or near assumed sewer main elevation?�(]Yes ❑No <br /> Are there fixtures in ihe house located below the upsUeam se�ver manhole rim eievation? �Yes ❑ No <br /> Is lhe side sewer currenily UNPROTECTED Bom Sewer backup.;(does nol have a BWD installed)? �'Yes ❑No <br /> Site Inspection Checklist: <br /> A!1 items must be checked'Yes'belore inspection is considered complefe � <br /> Was side sewer N inspected from building to sewer mainT ��Yes ❑No Condi6on: I <br /> Does side sewer have at least 1%slope(rom the building to sewer main? �Yes ❑No Describe: <br /> i <br /> Have ali building sewer drain connections to the side sewer been itlentifiee and localed? �'Yes ❑No i <br /> Have all properly slorm drainage connedions to the side sewer been identified and located7 �'Yes ❑ No � <br /> Has property been evaluated for drainage defidencies with findings comr�iunicaled lo property owner? �Yes ❑No ' <br /> i <br /> Installatian Details: i <br /> What type and brand o(BWD was installed at Ihis e Clean Check B nder pump,etc.): � <br /> Where was the device installed(general description,atlach map)? ���ch �u, ,� ,.!6 .+��✓ .�.r n cr ` <br /> AP/L�r 10 � 0 1 /, • �c% ` <br /> Was lhere any other sewer or slorm drainage�vortc completed in conjunction with the BN'D work?Is so please describe:_ <br /> ,✓/-� <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnecled from upslream of the BWD? �'Yes ❑No Commenls:__ <br /> Does BWD posilioning meels minimum slope requirement a(>1%? ,�Yes ❑ No Commenls: <br /> Can BWD be pulled oul(or inspection and mainlenance after loosening thumb screw?�Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened?�Yes ❑No <br /> Circle the BWD cov mgaGon cover Qandscape are raKc load bearing cover(drive sudace)/access halch(building) � <br /> Was property owner sho�m the location of lhe installed BWD?�Yes ❑ No Commenls:_ � <br /> Property Owner's Signatur : �' ����� Date: 12/3�/i`/ ! <br /> Installcr'sSigna�ur s— _ Date: Iz�JG���J <br /> Revision:2 1 Friday,September 12,2014 <br />