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BACKWATER PREVEN`iION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contacl Info: ��°nMPgFIl�S PLv6'�3 IN�> , fN( , <br />Date Bacicwaler Prevenlion dev�ce (BWD) �vas installed: Gl i Date lhis form was completed: I( 2� 1�/ <br />Installation Properly Owner Name and Contact Info: QPR P� A{� P� k-�-� ^� <br />Property Address: <br />Pre•Installation Inspection Checklist: <br />All items musf be checked 'Yes' in order /or a BWD to be considered for installa�ion <br />Is lhere a basemen( or level of the house Ihat is at or near assumed sewer main elevation? 0'�es ❑ No <br />Are there fixlures in lhe house located below the upstream sewer manhole rim elevation? Yes ❑ No <br />Is the sitle sewer currently UNPROTECTED irom sewer backups (does nol have a 8WD installed)? ��s ❑ No <br />Site Insoection Checklist: <br />All items must be checked 'Yes' beiore inspection is considered complefe <br />Was side sewer N inspected irom building lo sewer main? [�'Yes ❑ No Condition: �1 ��a (� <br />Does side sewer have at least 1% slope from the building to sewer main? �� ❑ No Describe: _ <br />Have all building sewer drain connections to the side sewer been identifed and located? �s ❑ No <br />Have all propert f slorm drainage conneclions to lhe side sewer been identified and lo�ated? �NNes ❑ No <br />Has property been evalualed for drainage deficiencies wilh findings �ommunicated to property owner? es ❑ No <br />Installation Details: <br />What type and brand o( BWD was install2d al this site (Clean Check DWV, Grinder pump, etc.): C l.bf�*-� �+{IxIL <br />Where H�as the device installed (general d�scriplion, attach map)? I ti (�?•G.Pci� —('l^fk� �1+�.crt�.1� <br />Was Ihere any other sewer or slorm drainage work completed in conjunclion wilh the BWD work? Is so pleasa describe: },�j <br />Iristallation Checklist: <br />Are all downspouts and site drainage disconnected (rom upstream o( Ihe BWD? es ❑ IJo �omments: _ <br />Does BWD posilioning r�eets minimum slope requirement o(>t%? Lyxes ❑ No Comments: <br />Can BN�D be puiled oul (or inspection and mainlenance after loosening lhumb saew? es ❑ No <br />Is BWD locked iNo the pro er osition and thumb screw tightened? es ❑ No <br />Circle lhe BWD cover. i ation cover (landscape area) lre(fc load bearing cover (drive sur(ace)1 access halch (building) <br />Was properly ovmer shown lhe location o( the inslalled BWD? Yes ❑ No CorrmeRts: <br />�'� Property O�vner's Signature: � �� �• � Qate: � � "���'�`� <br />Install�� s Signalure: __ _ Date: i� �(Z�� f <br />Revision: 2 1 Monday, September 15, 2014 <br />