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BACKWATER PREVEN710N DEVICE FINAL <br />E,, INSTALLATION CHECKLIST <br />,�r���-� c«n �-;(+ � G� s�� e���, L LG <br />� ., _ <br />Installation Company Name and Contact Inio:J� <br />Date Backwater Prevenlion device (BWD) was insla <br />Instaliation Property Uwner Name and Contact In(o: <br />Property Address: ���L:(�1_l.! <br />-� <br />Date this form was completed: <br />Pre-Installation Inspection Checklist: �" <br />All ilems musl 6e checked 'Yes' in order (or a BWD lo be considered for instaliation <br />Is there a basement or level of Ihc hou:e that is at or near assumed sewer main elevation? [�'es ❑ No <br />Are ihere fixtures in lhe hnuse incated below the upsiream sewer manhole rim clevaGon"1 �i(es ❑ No <br />Is the side sewer currently UNPROi ECTED from sewer backups (does not have a BWD installed)? [�Yes ( J No <br />Site Inspection Checklist: <br />Ail items must be checked 'Yes' before :nspection is considered complete /� �,� J <br />Was side sewer TV inspecled trom building lo se��r.r m�in? [�Nes ❑ No Condilian: _��XY�t� <br />Does side sewer havc at least t%slope trom Ihe building lo sewer main? [�'es ❑ No Describe: <br />Have all building sewer drain conneclions to the side sewer been identilied and localed7 ��'es ❑ No <br />Have all prnperty storm drainaye conncetions to the side sewer been identified and located? j�'es ❑ No <br />Has property been evaluated (or drainage deficiencies with findings communicaled to properiy owner? [–�'es ❑ No <br />In�`:Ilat�on Details: ��� <br />Whal fype and brand of BWC �vas installed ai Ihis sife (Clean Chec'a BNN, Grinder pump, etc.): � ��`'�� <br />Where v�as I!�e devir.e ��s!s�led (general descripiion, allach map)7 ,�� C��Q����� <br />Was there any other se�ver or slorm drainage work compleled in conjunction wilh ihe BW� work? Is so plr.ase describs: _ <br />- --- -�l�rvt� <br />installation Checklist: <br />Are ail doeJnspouts and site drainage disconnected from upsiream o( lho BWD? � Yes �] No Comments: ___ __ <br />Does BWD positioning meels minimurn slopc requiremenl of >t%? ��'(es ❑ No Comments: _ __ __— <br />Can DWU 6e pulled out for inspeclion and maintenance ailer loosening Ihumb screv�?�Yes ❑ No <br />Is DWD locked into the pra�:r posifinn and Ihumb scre�v tighir.ned? ��Yes j� No <br />Circle ihe BWD r.over�. imgalion covei (lat��C scape �rea; ! tra((ic Ioad �earing cover (dnve surfa�e) ! access halch (building) <br />LNas property oerner sli�wr+-tl�i6c51ion oi Uie inslalled BWD'? ,��'es ❑ No Commenis: `___ <br />� z—.- �� �� <br />Properly Ovmer's Signalure: _ � f �n�" Datc: J �-� <br />Inslaller's Signat�e' �,_� �Y� _ --_— –. — -.__ _ Date: _�� —�/ <br />Hcvision:2 � � 1 friday, S�pir.mbcr 1J., 2014 <br />