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i <br /> , BACKWATER PREVENTION DEVICE FINAL <br /> ' �, INSTA�LATION CHECKLIST <br /> Installation Company Name and Gontact Inia �974- Ql �� . z -- $ —�/L <br /> Date Backwaler Prevention device(BWD)was instailed: l Date ihis(ortn was completed:,f�0/L�. 7.��1$^ <br /> Inslallation Property Ownar Name and Con!act Info: l�I.t� ����-��-w /�� �� !��_ <br /> PropertyAddress:��(�Jc.� �— <br /> Pre-Installation Inspecfion Checklist: <br /> AI!items musf he checked'Yes'in order for a BWD fo be considered for installafion <br /> Is ihere a basement or level oi Ihe house ihat is at or ncar assumed sewer main elevation?,�'Ves ❑No <br /> Are there fixtures in the house loeated below the upsUeam sewer manhale rim elevalion?[�'�s ❑No <br /> Is Ihe side sewer currentiy UNPROTECTED hom sewer backups jdoes not have a BWD instailed)?[�ies ❑No <br /> Site Inspectfon Checklisl: <br /> qfl items musf 6e checked'Yes'be%re inspecfion is considered compfete <br /> Was side sewer N inspecled fram building to sewer main? �'Pes ❑No Condilion: (JYLI S u��k G�u=� ak <br /> Does side sewer have at least 1%slope from the building to sewer main? [�YYes ❑No Describe: <br /> Have all building sewer drein connecfions lo Ihe side sewer been ident�ed and located? (I�Yes ❑No <br /> Heve all property stortn drainage connealions to the side sewer been identified and lo�ated? [�'Y8s ❑No <br /> Has property been evalualed for drainage deficiencies�vith findings communicated lo property ownef? (��s ❑No <br /> Installation Details: <br /> Whal type and brand of BWD was inslalled at this sile(Clean Check BVJV,Grinder pump,elc.}: ��i�u- ���ecf� ' <br /> Where was the device installed(general descriplion,attaeh map)7 �w� FiGs^'� Pr1�_ <br /> •-�e.` rv��YP • <br /> Was Ihere any olher sewer or stortn drainage work compteted in conjuncGon wilh ihe BWD work?Is so please describe:_ <br /> N�m-�- - <br /> Installation Checkltsl: <br /> Are all downspouts and site drainage disconnected from upsiream o(lhe BWD? [a'Fes ❑No Comments: �u �' <br /> Does BWD positianing meets minimum slope requirement of>1°�? [�}'�s ❑No Commenis: <br /> Can BWD be pulled oul tor inspeclion and maintenance afler loosening Ihumb screw? ��s ❑No <br /> Is 9WD locked into the p�per posiGon and Ihumb screw lighlened? �fe"s ❑No <br /> Circle Ihe BWD cover:irtigation cover(landscape area iraffic load earing cover(drive surface I access hatch(butlding) <br /> Was property owner shown the IoeaGon of ihe installed BWD? �s ❑No Commenls: <br /> Property Owner's Signalure. 1� , Date: y—/�—iS` <br /> Installer'sSignature: Date:��21.� �.fT 2�7-3! <br /> Revision:2 1 Friday,Septem6er 12,2014 <br />