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� <br />BACKWATER PREVENTION DEVI�;E FINAL <br />INSTALLATION CHECKLIST' <br />Installation Company Name and Contact Inio: /� ;,. r—�,�,c-,Zi: ti c:� <br />Date Backtvater Prevention device (BW�) �vas instai!ed:_/,r � � Dale Ihis form �:-as compleled: %?s •,/ <br />!nstallation Property Owner �ame and Cyntact Infa <br />Property Address� <br />Pre-Installation Inspection Checklist: <br />All items rnusl be cheeked 'Yes' in order for a BWD to be considered for insfallation <br />Is there a basemenl or level oi ihe house lhat is al or near assumed sewer main elevalion? � Yes ❑ No <br />Are lhere fxtures in lhe house localed bzlow Ihe upstream sewer manhole rim elevalion? 'es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer hackups (does not have a BWD ins:alled)? 'es ❑ �o <br />Site Inspection Checklfst: <br />All items must 6e checked 'Yes' befae inspection is considered complele <br />/ <br />Was side se�ver N inspecled from building to sewer main? [vl Yes 0 No Co dition: C�000 Pnti e,zc:T� <br />Does side sewer have at least 196 slope from the building lo sewer main? Yes ❑ No Describe: <br />Have all 6uilding sewer drain connections to the side sewer been identified and lorated? �s ❑ No <br />Have all property storm drainage con�ections to the side sewer been identified and located? �es ❑ No <br />Has propedy been evaluated for drainage deficiencies wilh findings communl�ated to propedy owner? 0 s❑ i�o <br />Installation Detafls: <br />What type and brand of BWD was instaVed at lhis sile (Clean Check BNN, Grinder pump, elc.) eL-tuv.� cU ec-1< <br />Where was Ihe device installed (general description, aflac ap) _ <br />Was lhere any other sewer or slorm drainage �vork completed in conjuncGon u�ith the BIND �:�ork? Is so p!ease describe: _ <br />Installation Checklist: <br />Are all do:�rnspouls and site drainage disconnected lrom upslream ol ihe BWD? ��Yes ❑ No Commenls: <br />Does B1VD posilioning meets minimum slope requiremenl of �1°09 �'Yes ❑ No Comments: <br />Can BWD be pulled oul for inspeclion and maintenance a(ler loosening ihumb screw7 L�'es �� No <br />i <br />Is 81ND locked into the proper posifion and ihumb screw lightened? Q"Yes ❑ No <br />Circle the BWD cover: irri�3tion cover (landscape area) I traffic load <br />INas propery o�mer shown the <br />Property Uvmer s Signature: <br />Installer's Signature: �,i <br />Revision: 2 <br />of the instalied BWD7 <br />cover(drive sudace�laccess hatch (building) <br />❑ No Comrnenls: <br />Date: %' � � -- � <br />Date: 1r1��2 �2oi� <br />Tuesday, September 16, 2014 <br />