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gACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Inslellation Company Pieme and Contact Into: �.�x�I' ��Gs�r1�/e_ <br /> Date Backwater Preverition device(3WD)was installed: � 2I�i � �4 Date this form was complzted: I L i Z ► <br /> Installatlon Property Uwner Name and Contact Inio: ]�iV�1�U Q I��`�-/ <br /> PropeRy Address; �SI�.0 �111:�1"� <br /> Pn•Installation lnapection Checklist; <br /> AN Rems must be checked'Ves'in order for a BWO to 6e considered for insfelfaBon <br /> Is there a basemenY or lavel of the house that is at or near assumed sewer main eievatlon?�Yes ❑No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation9�Yes ❑No <br /> Is the side sewer currently UNPROTECTED(rom sewer backups(does not have a BW�installed)7'�Yes ❑No <br /> Slte Incpactlon Checklist: <br /> All items must be checked'Yes'belore inspec8on is considered complete <br /> Was side sewer N inspected from building to sewer main? �Yes ❑No Condifion: � <br /> Does side sewer have at least 1°�slope from the building to sewer main? �Yes ❑No Describe; <br /> Have all building sewer draln connections to the side sewer been idenfified and located7 �Yes ❑ No <br /> Heve ali FropeAy storm drainage connections to the side sewer been identiAed and located? '�Yes ❑No <br /> Has propeRy been evaluated for drainage deTiciencies wilh findings communicated fo propeAy owneR �Yes ❑No <br /> Insfallatlon Dehtls: I <br /> What type and brand of BWD was installed at thls sfte(Clean Check BNN,GrinId,e,r pump,etc.): a�.ffa,V1 C_1r�1_[�-�L <br /> Where was the devfce instailed(general description,aHach map)? /�� Y6�I�Q. <br /> Was lhere any olher sewer or storm drainage work completed in conjunction with the BWD work7 Is so please describe:_ <br /> �� , <br /> InafalNdon Checkliet: <br /> Are all downspouts and sRa drafnage disconnected from upstream of the BWD7 (�I Yes ❑No Commenta: <br /> Does BWD positioning meets minimum slope requiremant of>1�? �Yes ❑No Comments: <br /> Can BWD be pulled out for inspeclion and maintenance after loosening thumb screw? �Yes ❑No <br /> Is 8WD locked into the pro er d thumb screw tightened? �Yes ❑No <br /> Clrcle the BWD cov :irrigado landscape are I lraffic load bearing cover(drive surface)!access hatch f building) <br /> Was property owner shown the location of the nstalled BWD? �(Yes ❑No Comments: <br /> Property Owners Signatur • ,� Date: /3- 2 <br /> InstaltersSignature: �r�C.l2 cl,�c Date: I Z� �2 �� <br /> Revision:2 1 Friday,September 12,2014 <br />