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i <br /> ; <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL j <br /> INSTALLATION CHECKLIST `. <br /> ; I <br /> . <br /> ; <br /> ! <br /> Inslailation Company Name and Contact In(o: u �►-�U' C i <br /> Date Backwater Preventlon device(BWD)was inslalled: 7 / Date lhis form was completed: � <br /> installation Properiy O�vner Name and Conlact Info: j <br /> Property Address: � � `� W�7 M A�-�' h7i S �� r �.. �L"7^ w�a I <br /> 1're-Installation Inspection Checklist: <br /> i <br /> All items musf be checked`Yes'in order lora B�ND lo be considered forinstallation i <br /> i <br /> Is there a basement or level o(Ihe house Ihat is at or near assumed sewer main elevation?�Yes ❑No � <br /> � <br /> Are lhere fixtures in the house lorated below the upstream sewer manhole rim elevation? Yes ❑No f <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD insialled)?�Yes ❑No f <br /> Site Inspection Checklist: `y <br /> � <br /> All dems must be checked'Yes'6e(ore inspection is considered complefe I <br /> � <br /> Was side sewer N inspecied from buildiny lo sewer main? �Yes ❑ No Condition: � OK � <br /> Does side sewer have al least 1�o slo e from the buildin to sewer main? �J Yes � <br /> p g ❑No Describe: ; <br /> Have all building sewer drain connections to the side sewer been idenGLed and lorated? �Yes ❑�o � <br /> Have all property storm drainage wnneclions to ihe side sewer bcen identificd and loratedl �Yes ❑ No ' <br /> Has property been evaluated(or drainage deficiencies with findings communicated�o pmpedy owner? �Yes ❑No ? <br /> Installation Details: ( <br /> What type and brand of BWD was installed at this sit heek 6WV,Grinder pump, ete.):rLC�1}�—� L�EFt�� � <br /> Where was lhe device inslalled (general descriptio ,attach map)? ; <br /> i <br /> _ ; <br /> Was there any other sewer or storm drainage�vork completed in conjunclion with Ihe BWD worx?Is so please descnbe:_ i <br /> Installa6on Checklist: i <br /> Are all downspouts and site drain�ge disconnected(rom upsiream ol the BWD? �Yes ❑ No Commenis: � <br /> Does 6lND positioning meefs minimum slope requiremenl of>1%? �Ycs ❑No Commenis: I <br /> i <br /> Can BWD be pulled out for inspection and maintenance afler loosening umb screw? �Yes ',]No � <br /> is BWD locked inlo Ihe proper position and ihumb screv�fightened? ,�Yes ❑No ' <br /> i <br /> Circle the 8WD cover. irrigation cover(landscape area)I traKc load bearing cover(drive sudace)1 a�cess hatch(building) ; <br /> Was properly owner shown the IocaGon oi ihe installed BWD? �ryt�,.,�Yes ❑No Commeois:, � <br /> Property Owner's Signalure. � �'�� "`U '� Date: � ��Y i <br /> � �- --�� � <br /> Insfaller's Signalure:� _�� Da:e:�� � � � <br /> Revisiorr. 2 1 Tuesday,September 16,2014 � <br /> { <br /> i <br />