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1 <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKUST � <br /> i <br /> " <br /> Installation Company Name and Contact Info: ���R�' ��� � II <br /> Date Back�Vater Prevention device(BWD)was inslalled: C, z Date this torm was completed: �/ 3 / i <br /> InstallaUon Propedy O�vner Name and Contact Info: C�i/r s ,��r-IFSo� � <br /> Property Address:�'�j; Te//c'icG l�� � <br /> Pre•Instailation Inspec6on Checklist: � <br /> i <br /> All ilems must 6e checked'Yas'in order for a BWD to be considered for instalfa6on ; <br /> i <br /> Is fhere a hasement or level oi the house that is at or near assumed sewer main elevation7 Yes ❑No <br /> Are there fxtures in',ne house locate�i belova ihe upstream sewer manhole rim elevation?�Yes ❑No � <br /> Is the side sewer currently UNPROTEi,TED irom sewer backups(does not have a BWD Instalfed)7�Yes ❑No � <br /> Site Inspection Ch�cklist: ; <br /> All items must be che�:ked'Yes'befo�e inspection is considered complete i <br /> Was side sewer N in�•oe�ted from building to setver main7 �[]Yes ❑No Condition: <br /> i <br /> Does side sewer have�it least 1°�6 slope irom the building to setver main? �Yes ❑ No Describe: <br /> Have all buiiding sewer drain connections to the side setiver 6een identified and located? �Yes [] No � <br /> Have all property stam drair�ege conne�tions to the side sewer been identified and lo�ated7 •Yes ❑ No ' <br /> Has properiy been evaluated far drainage deficiencies with findings cammunicated to prope o���ner? �j Yes ❑No <br /> Installation Details: �--� ; <br /> N�hat type and brand of BWD�vas installed at this ' .!Clean-Ghec�c B�VN! Otinder pump,etc.): � <br /> INhere tivas'he device installed(general description,attach map)? �%hT �.r�.e n � , ��s��'n �+��_ i <br /> Was lhere any other setiver or storm drainage vaork completed in conjunction with lhe BIND work? Is so plPase describe:_ � <br /> j <br /> Installalion Checklist: � <br /> Are all downspouls and site drainage disconnecled irom upsVeam of lhe BWD7 ❑Yes ❑ No Comments: ' <br /> Does BWD positioning meets minimum siope requirement of>1%? ❑Yes ❑No Comments: ; <br /> t <br /> Can BWD be pulled out for inspection and maintenance after loosening lhumb screw? ❑Yes ❑No <br /> Is BWD locked into the proper position andlh crew tightened7 ❑Yes ❑No � <br /> Cirde fne BWD cov :' atio cover(landsca o ea) traffic load bearing cover(drive suda�e)I access hatch(building) ' <br /> Was property owner shown the loc l�fthe-instalfedBWD? ❑Yes ❑No Comments: ; <br /> ; <br /> � <br /> Properly Ovrner's Signa e: .----� Date:��7/i� � <br /> Installers Signatu . - - - Date: 3��7//S i <br /> � <br /> Revislon: Z 1 Friday,Sep[ember 12,2014 j <br /> � <br />