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f <br /> i <br /> BACKWATER PREVENTION DEVICE FINAL ' <br /> INSTALLATION CHECKLIST � <br /> i <br /> � <br /> Inslallalion Company Name and Contact Info: 1� � C' ' <br /> Dale Backwater Prevention device(BWD)was installed: Date this form�vas compleled: � <br /> � �` , <br /> Installation Property ONmer Name and Contact Info:�P � I�LA(C��I � <br /> Property Address:��!1�� � �C`C YY�I�Q j <br /> � <br /> Pre•Installation Inspection Checkliet. <br /> All ifcros must 6e checked'Yes'in order for a BWD to be considered for installation � <br /> Is Iherc a basement or level of the house Ihal is at or near assumed se�ver main elevation?�Yes ❑No i <br /> Are there fixtures in Ihe house locatetl below ihe upstream sewer manhole rim elevation?[�Yes ❑ No ' <br /> i <br /> Is lhe sidc sc�ver currently U�'PROTECTED irom sevrer backups(does nol have a BWD inslailed)7❑Yes ❑No � <br /> i <br /> Sife Inspeetion Checklist; <br /> All items must 6e checked'Yes'before inspection is considered complete ! <br /> Was sitle se�ver TV inspected Irom building to sewer main? �Yes ❑No Condition:p��Jtk � 5�'f.k F ��r� i <br /> Dces side sev,�er have at least 1%slope from ihe buiiding to sewer main? �Yes ❑ No Describe: � <br /> Have all building sewer drain co�nections to ihe side sewer been identified and located? �Yes ❑No i <br /> Have all property storm drainage connections to ihe side sewer been ideNiSed and localedl ]�Yes ❑No � <br /> Has properly been evaluated fnr drainage deficiencies with findings communicated to properly ovmer? �Yes ❑ No � <br /> i <br /> Installation Details: i <br /> What type and brand of BWD was installed at Ihis site(Clean Check BWV,Grinder pump,elc.): �uc C l�eu��Cl�cla; i <br /> Where was lhe device instaUed(general description,atlach map)? I�1 S�� 3ne3,vwM� a., wur+,. 5�.�.,�! � <br /> 1.::,u. � <br /> !W� as ihere any olhcr sewer or stomi draina;-yfe vrork completed in conjunction with lhe BWD work9 Is so please descrih�:_ � <br /> ["tih51{�-Lc:.•_,,_.1c,R_G.s�l� �uuCa,� Cr cxli'�1 �lZ'1v..•. C1..,o. �. .y� Tj��:�Ca � <br /> Installation Checklist: � <br /> i <br /> Are ail dovmspou�s and site drainage disconnecled irom upsiream o(Ihe BWD? [�Yes ��No Commenis: C�k 5k.'�i�, j <br /> Does BWD posilioniny mccls minimum slope requiremenl o(>t"/o? D.Yes ❑No Commenls: � <br /> Can BWD be pulled out(or inspection and maintenance afler loosening thumt scre�v? n Yes ❑No � <br /> Is BWD locked inlo Ihe proper posi�ion and lhumb screw tighlened7 ��'es ❑ No � <br /> Circle lhe BWD cover.irrigalion cover(landscape area)!iraffic loatl bearing rover(drive suriace)I accr.ss hatch(builriing) � <br /> Was property owner shovm the location of the installed BWD? �Yes ❑No Comments �`�"�'`«�S`����`— <br /> Property Ovmer's Si ure: Date� ��Ct�//� i <br /> InslallersSignalur � Dale: ��'"�"�� i <br /> 1 <br /> Revision: 2 1 Friday,Septemher 12, 2014 � <br /> 1 <br /> ; <br /> i <br />