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i <br /> � <br /> : <br /> � BACKWATER PREVENTION DEVICE �tNAL 3 I <br /> INS7ALLATION CHECKLIST � ! <br /> I <br /> Instailafion Company Name antl Contacl Into;�u�.e�a_.�,-�'l� �- IlC. ' <br /> Date Backwater Prevenfion device(BWD)was Installed: �Dete t�is ftxm Kav crompleted� ' <br /> � <br /> ,Instailatlon Prop�rty pwner Name and Con;a�l Inb: � <br /> ProPertyAdOres?:� J ���e���9��� <br /> F <br /> Pre•Installadon Inspection Checklist: <br /> A�l items must be checked'Yes'in Order kr a BWD to be considered lor insf8!laion � <br /> Is there a b3semeni or level of the house that is at or near assumed se�rer main ele�etlon?[�J Yes ❑No <br /> Are ihere fixtur�s In ifie h0use Ixated b aw the ups7eam sewer manhole nm elevation7,�Yes ❑No <br /> Is�he side sewer currently UNPROTEC7ED irom se�var ba�kups(does not have a BWD insta;led)?(�Yes ❑No <br /> Slte Inspectlon ChecklisY. <br /> All ilems must De checketl'Yes'DePore lnspacNon is consrdeied oanplg;e ; <br /> Was side sewer N inspe�ee from buibing to sewer main? �Yes ❑No Cond�ipn: <br /> Dces slde sewer nave a;least t°/,slope from the Gullding b se�ver main4 [�Yes ❑No Describe: <br /> Have all building s2�ver drain connections M the side eewer pean Identified and located? �Yes ❑No <br /> Have all pmpetty storm dralnage wnnec5ona to the s�Ce sewer heee identiAed a�Ixated7 (�,Yes ❑Np ' <br /> Has propetty been evaluated hr dralnege deficiendes wRh findings communicated to proper,y oNner? [)�Yes [�No <br /> Instaliallon bedils: ' <br /> What type entl b�and ot 8WD was installed at this stte(Gean Check RWV, Gnnder pump.etc.): 1 eav�c h P.G� <br /> Where was the device Ins�elled f general des�ripfion,aaac�map)7 • �-^ ;d1.a lnov 5 e. ' <br /> ! <br /> Wes the2 eny aAer eewer or stamt drainage work completed in wnJurctlon with ihe BWO�wrtQ Is so please descnbe: j <br /> _r 0 ; <br /> InsUlletion Cheekllst; � <br /> Ars afl davnepouts and si�dreinage disconnected from u �reem of the BWp? 4 <br /> ps'r �jYes ❑No Comments: , <br /> Does BWD pwifioning mBets minimum slope mquirement of>t%? �Yes ❑ Na CommCnta; <br /> Can BINU be pulled out for inspeclion and maintenance a};er loosening thumb screw7 �Yes ❑No <br /> Is BWD Ixked Into the proper posltiun e ' umb screw tighlened?.�.Yes ❑Na ! <br /> Grde Ne BWD cover.iRlg2tlon co r landsceps area 1 traffiC load beadng cover(drive surac�)I acxu hetch(building) ' <br /> Was property amer shrnvn the locati n of Ne M Iled BW�7 �Yes ❑��o Comments: <br /> Property Owners Slgnatur : 9 , Date: %J ' <br /> Inslelier'sSigna(ure: CR p�e; 1� � �' i <br /> RevisiOn:2 1 Frtday,Sep:cmber iZ,2014 ' <br /> i <br /> � <br /> � <br /> I � <br /> i <br />