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�ACKWATER PREVENTION DEVICE FIN�4L <br /> INSTALLATION CHECKLIST <br /> Installatiop Company,Name and(;�ntact Info: �h�6 �S p�u�,b�,� �hc. <br /> Date Backwaler Prevention device(BWD)was installed: /4- 3/'/�/ Date this form was compieted: %4!-3L—/i[ <br /> Installation Property Owner Name and Contact Info: �aT fe�y,�w,�sd.� <br /> PropertyAddress: /725 �uc-�¢� �tv2 LTVP.�r�'�} l.��t �i S'Z�/ <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order tor a BWD to 6e conside�ed for installation <br /> Is there a basement or level of the house that is at or near assumed sewer maj.n elevat'on? Yes ❑No <br /> Are there fixfures in the house located below the upsheam sewer manhole rim elevation? es ❑No , <br /> Is the side sewer currei�tly UNPROTECTED from sewer backups (does not have a BWD installed)7 • es ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complete <br /> Was side sewer N inspected fron,.,uilding to sewer main? �es ❑ N�o �C ndition: <br /> Does side sewer have at least 1%slope from the building to sewer main7 �1'es ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [�Yes ❑ No <br /> Have all property storm diainage connections to Ihe side sewer been identified and located? ['Yes �N . <br /> Nas property been evaluated tor drainage defioiencies with findfngs communicated to property owner? �s ❑No <br /> Installation Details: <br /> What type and brand of BWD wes installed at this site(G�an Check BWV, Grinder pump,etc.): <br /> Where was the device installed(general description,attach map)? ✓�os�f 2� s'�c�� (�.ric do�l.e of G�oure <br /> ap�✓'ax•r.a. C�� o F' ca n cre�e s�u6yv v.�,E �� <br /> Was Ihere any oihen sewer or storm drainage�vork completed in conjunction wilh the BWD work7 Is so please describe: A(0 <br /> Installation Checklist: <br /> Hre all downspouls and site drainage disconnected from upstreain of the BWD7 �es Q No Commen�s: <br /> Does BWD positioning meets minimum siope requirement of>i%? �Yes ❑No Comments: <br /> Can BWD be pulled out tor inspection antl maintenance after loesening lliumb screw? [�Yes ❑No <br /> Is BWD locketl into 4he proper osition and thumb screw tlghtened7 �es ❑No <br /> Circle the BWD cover irrigation cover landscape area)I traffic load beanng cover(dnve surface)/access halch(building) <br /> Was propeRy owner shown e ocation of the installed BWD? �es ❑ No Commenls: <br /> Property Owner's Signature; Date:__ <br /> r <br /> Installers Signature:� ,o�S• o.�� Date: f`J - 3/-/t� <br /> Revision:2 . 1 Monday,September 15, 2014 <br />