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� <br />� <br />BACKWATER PREV�NTION DEVICE FINAL <br />INSTALLAI'ION CHECKLIST <br />InstallaGon Company Name and Contact Info: /�%�r[l� P�vr,o 3in�Gc �D La - 4DCo_- O 9Z9 <br />Date Backwater Prevention device (BWD) was inslalled: /Z- !-�¢ Date ihis form �vas completed: <br />Installation Property Owner Name <br />Property Address: <br />Contactinto: K�Tk:Ln•� <br />Pre•Installatian Inspection Checklist: - <br />All ifems must be checked 'Yes' in order (or a BWD fo be considered lor installation <br />Is there a basement or Ievel oi the house that is at or near assumed sewer main elevation?�Yes ❑ No <br />Are there fixtures in the house located below lhe upstream sewer manhole rim elevation?�Yes ❑ No <br />Is the side sewer currenlly UNPROTECTED from sewer backups (does not have a BWD inslalled�? � Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' 6e/ore inspection is considered complete <br />Was side sewer N inspecled from building to sewer main? � Yes ❑ No Condition: <br />Does side sewer have al leasl 1°/a slope from the building to sewer main? j� Yes ❑ No Describe: _ <br />Have all building sewer drain connections to the side sewer been identified and located? � Yes ❑ No <br />Have all property storm drainage connections to?he side sewer been identified and located? �] Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owne�? 7� Yes ❑ No <br />Installation Details: <br />What tyFa and brend oi BWD was installed at this site (Clean Check BNN, Gnnder pump, etcJ: C' C�-nu Ck�cK <br />Where was the device installed (general description, aflac map)? <br />1h'as there any other sewer or storm drainage work wmpleled in conjunclion with ihe B14iD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected irom upstream of ihe BWD7 ,�],Yes ❑ No Commenis: <br />Does BWD posilioning meels minimum slope requirement of >t%? � Yes ❑ No Comments: <br />Can BWD be pulled out tor inspection ard maintenance after loosening thumb screw? (� Yes ❑ No <br />Is BWD locked inlo lhe proper posi6on and thumb screw Gghtened? � Yes ❑ No <br />Circle the BWD cover: irrigation cover (landscape area)1lraKc load bearing cover (drive surface) f access hatch (building} <br />Was property owrer shown the location of Ihe installed BWD? � Yes ❑ No Comments: <br />�Property Owner s Signature: 'r Date: � � _ <br />Installer'sSignature: Dale: �2— i- �� <br />Revision: 2 <br />i <br />Tuesday, September 16, 2014 � <br />