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BACKWATER PREVENTIC�N DEVICE FINAL <br />� INSTALLATION CiiECKLIS �' <br />Instailation Company Name and Contact Info: - ��� b✓�� � �.Z� �� ��lz � <br />Date Ba�kwaler Prevention device (BWD) was installed:s"'� `l —� S ate this form was compleled. '1 �'� <br />Installation PropeRy Owner Name and Contact Infa �,''�".� ���� � <br />P�opertyAddress: % �c>I �`T3 :-' t� <br />Pre•Installation Inspection Checklist: <br />All items musf be checked'Yes' in order for a BWD to be considered /or installation <br />Is there a basement or level of the house thal is at or near assumed se�ver main eievalion? [�fes ❑ No <br />Are there fixtures in the house located below ihe upsiream sewer manhole rim elevalionl [�Y�s ❑ No <br />Is the side sevrer currently UNPROTECTED from sewer backups (does not have a BVVD installed)? �(]Xes ❑ No <br />Site Inspection Checklist: <br />AII items must be checked 'Yes' before inspecfion is considered complete <br />Was side sewer TV inspected trom building lo sewer main? [}�`es ❑ No Contlition� <br />p lC <br />Does side sev�er have at least 1% slope from the building to sewer main7 �fes ❑ No Describe: <br />Have all building sewer drain co�nections to lhe side sewer been identified and localed7 ][�Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? �=e6 ❑ No <br />Has property been evaluated for drainage deficiencies with findings communi�ated to property o�vner? ❑ Yes ❑ No <br />Installation Details: � �_�C <br />What type and brand of BWD �vas installed at this si (Clean Check BW inder pump, etc.): <br />Where was the device installed (general descriplion, attac map)9 � v�-�°-P <br />Was there any other sewer or storm drainage wo�k �ompleted in conjuncfion with the BWD �.vork? Is so piease describe: _ <br />� <br />Installation Checklist: <br />Are all do�vnspouts and site drainage disconnected (rom upstream of the BWD7 [e]�'�s ❑ No Comments: <br />Does BWD posilioning meets minimum slope requirement of >1%? [�-Yes ❑ No Commenls: <br />Can BWD he pulled a�t tor inspettinn and maintenance after loosening thumb screw? ❑ Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? es ❑ No <br />Circle the BWD cover: irrigalion cover (landscape area) raffic lor. ' bearing cove (drive surface)1 access halch (building) <br />Was property owner shoem the location of ihe installed BWD'i � 1`es No Comments: <br />Property Owner's Signature: �'� Date: � -� ` 2 �� S/ <br />z� � <br />Installer's 5ignaWre� Date: � / 9 ' �5 <br />Revision: 2 1 Friday, Septem6er 12, 2014 <br />