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i � <br /> BACKWATER PREVENTION DEVICE FINAL j <br /> �, INSTALLATION CHECKLIST � <br /> : ; <br /> � <br /> � Installation Company Name and CoMact Inio:�� <br /> l�w,b�ti - Zf= ��- ��� � <br /> i <br /> Date Backwater Prevenlion device(BWD)was installed: /� Z Date thls(ortn was completed:�ZO—C� ! <br /> Installalion Property Owner Name and Contact Into: fh^{������ ��r��� I <br /> Property Address: 23(Lv l,��G��-✓ �'� �'�� I <br /> Pre-InsWllaHon Inspeetion Checklist; <br /> Ai!ifems must be checked'Yes'in order lor a BWD to be considered lor insfallation , <br /> Is there a basement or level oi ihe house that is at or near assumed sewer main elevation?�� ❑No <br /> Are there fi�Aures in the house located below the upsVeam sewer manhole rim elevalion?[1�YC�s ❑No � <br /> Is the side sewer currently UNPROTECTED trom sewer backups(does nol have a BWD installed)?[L�'es ❑No <br /> Site Inspection Checklist: <br /> AII ifems musf be checked'Yes'be(ore inspecfion is cansidered complete � <br /> Was side sewer N inspected from building to sewer main? [►]N s��No Condition:_�V+� <br /> Does side sewer have al least 1%slope from the buildi�g to sewer main? [�'es ❑No Describe: <br /> Have all 6uilding sewer drain connecfions to the side sewer been idenlfied and located? �fes ❑No <br /> Have all property stortn drainage connections to lhe side sewer heen identified and located? [�]-Yes ❑No <br /> Has properly been evaluated for drainage defiae�cies wil�findings communicated to propPrty owne� �t�.-YEs ❑No <br /> I�stailatlon Details: l� <br /> What type and brand of BWD was inslalled at this sAe(Clean Cheek BWV,Grinder pump,elc.):�� <br /> Where was the device installed(general descdption,attaoh map)? <br /> �o,.nn,c^�-. <br /> Was there any olher sewer or slorm drainage work completed in conjunction witl�lhe BWD work7 Is so please describe:_ <br /> 1�t �37 n-�u�- �(J�^,�-A-� �Cn�"�$' ' <br /> Installation Checklist: <br /> Are all downspouts and sile drainage disconnected tram upstream of 1he BWD? [�'fcs ❑No Comments: ' <br /> Does BWD positioning meets minimum slope requirement of>t°/a? ��s ❑No Commente: , <br /> Can BWD be pulled out for inspe�tion and mainlenance afler loosening thumb screw? [�-Y�s ❑No <br /> Is BWD locked inlo ihe proper position and Ihumb screw lightened? 1r]a`es ❑No ' <br /> Circle the BWD cover: irtigalion cover(landscape erea)1 lraffic load bearing cover(drive suriace)I access hatch(building� <br /> Was property owner shown the location of Ihe inslalled BWD? �� ❑No Comments: i <br /> � <br /> Properly Owner's Signature: � U—``�` <br /> Dale: Y` <br /> Installers Signature� -�_i�� , " Date: �Z�JS ' <br /> i <br /> Revision:2 1 Friday,Sep[embcr 12.2014 � <br /> � <br />