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BACKWATER PREVENTION DEVICE FINAL <br />iNSTALLAT�ON CHECKLIST <br />Installa6on Company Name and Conlacl Info: <br />5- y�9-otZ <br />Dale Backwater Prevention device (BWD) was installed:l�—�� � ti� Date this fortn was completed: -- r�`� S <br />Inslaliafion Propedy Owner Name and Contact Info: "�V1'� o--v-k \ O��S �`" <br />Property Addrass: 2SZ 43 V l V��� �-� �- <br />Pre-Installation InspeCtion Ch�achlist: <br />A!I items must be checked 'Yes' rn order lor a BWD to 6e considered for installafion <br />Is there a basement or Ievei of the house that is at or iiear assumed sewer main elevalion? (�Yes L7 No <br />Are Ihere fixtures in Ihe house located below the upstream sewer manhole rim elevation? �s ❑ No <br />Is ihe side sewer currenlly UNPROTECTED from sewer backups (does not have a BWD installed)7 �'fzs ❑ No <br />Site inspection Checklist: <br />All items must be checked 'Yes' belore inspecfion is considered compfefe _ <br />Was side sewer TV inspec'ed from building to sewer main7 [�}-Yes ❑ No Condition: `'4Gl e�-�' <br />Does side sewer have at least 1% slope from Ihe building to sewer main? es ❑ No Describe: � <br />Have all building sewer drain connections to the side sawer been identified and located? [�-1`es ❑ No <br />Have all property stortn drainage ccnne�tions to Uie side sewer been idenHfied and located7 [�-Xer ❑ No <br />Has property been eveluated tar drainage deficiercies wilh findings communicated lo property owne�! �-1/es ❑ No <br />Installation Details: <br />What tyFp and 6rand of BWD was inslalled at this site ",�lean Check BWV, Gnnder pump, etc.): �� �°�C�c�- <br />Where was the device instailed (general descnption, attach map)? �-e-D ��P <br />Was there any other sewer or stortn drainage work compl ted in conjunclion with the BWD work7 Is so piease descri6e: <br />_ � l➢'�Q�" <br />Installatian Checklist: <br />Are atl down ;pouts and site drainage tlisconnecled trom upsiream ot lhe BWD? � es ❑ No Commenis: <br />Does BWD positioning meets minimum slope rec�uirement a(>1°h? �❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? 1[a-Y�5 ❑ No <br />Is BWD locked into Ihe proper posi6on and Ihumq scre_w�lighlened? ��s ❑ No <br />Circle fhe BWD cover: irrigalion cov (lands�ape area Jraffic load bearing cover (drive surface)1 axess hatch (building) <br />Was property owner shown Ihe locafio�o( lhe insl Iled BWD7 es ❑ No Commen4s: <br />Property Owner's Signalure: <br />Inslallers <br />Date:1a—�1' /S <br />Gale: �—1 1 •'� J <br />Revision: 2 1 Friday, September 17, 7.014 <br />