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BACKWATER PREVEMTION DEVICE FIMA,L <br />INSTALLATIOR� CHECKLIST <br />Installation Company Name and Contac! Inio: k97�1�1 �^� i� r n c� LL L �C � J`°i a�— <br />Y- <br />Date 6ackwater P�even6on device (BWD) was installed: C���I �• i 5 Date this fortn was completed: o- Ju- r�;� <br />Installation Property Owner Name and Contact Inio: �.,'�.,,_� �����l - <br />Property Address: �u U� � l V�l��l S ►/�'i.� - <br />Pre-Instailation Inspection Checklist: <br />All items must be checked 'Ye�' in crtier for a BWD to Ae considered for insfallation � <br />Is there a basemenl or level of Ihe house Ihat is al or near assumed sewer main elevation? es ❑ No i <br />Are there fixtures in the house located belcw the upslream sewer manhole rim elevation? es ❑ No ; <br />Is ihe side sewer currently UNPROTECTED irom sewer backups (dces �ol have a BWD installed)? �' es ❑ No ! <br />Site Inspection Checkiist: + <br />i <br />All 8ems musf be checketi 'Yes' be(ore inspection is considered co.mplete � <br />Was side sewer N inspected irom building to sewer main7 ��s ❑ No Condinon: TD I'Je Rn Pl���{A �"��" i <br />Dces side sewer have at least 1�o slope f�nm Ihe building to sewer main? (�'�es ❑ No Describe: <br />Have all building sewer drain wnnections to the side sewer 6een identified and tocated? [�-}�Yes ❑ No <br />Have all pmperty stortn drainage connections to the side sewer been identified and located7 D�s ❑ No <br />Has property been evaluated for d�ainage deficiencies with findings communicated to property ownet') �-[�'�'�s ❑ No <br />Installation Details: <br />Whal type and brand of BWD was installed al this site (Clean Check BWV, Grinder pump, etc.): �� c�.�e C�-e-c(L ' <br />Where was the device installed (general description, atlach map)7 �o O 1'1'� '(}� - <br />Was there any other sewer or slorm drainage work completed in conjunclion wilh Ihe BWD work? Is so please describe: _ <br />— ,41nnn - <br />Installatian Checklist: <br />Are all downspouts and site drainage disconnected from upstream oi the BWD� es ❑ No Comments: <br />Does BWD posifioning meets minimum siope requiremenl of >1%? ��s ❑ No Commenls: <br />Can BWD be pulled oul (or inspeclion and maintenance aRer loosening thumb :;crew7 �s ❑ No <br />Is BWD locked inb Ihe proper position and�hyQ����ew fighteneQ? � � No <br />Circle Ihe BWD cover. irtigation co�andsca area)� load bearing co e(drive surface) / access hatch (6uilding) <br />Was property ovmer shown ;�io !ocalion of the installed BWD? es ❑ No Commer.is: <br />Property Owner's Signa re-�-- _ u�.�, �o�c{ <br />Inslalier's Signalure: ��� <br />Friday, Septemher 12, 2014 <br />Revision: 2 <br />Date: �.�/ 'l.o i.i <br />Date: iP •— ��( — ZC l � <br />