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! <br /> i <br /> BACKWATER PREVENTION DEVICE �INAL � <br /> INSTALLATION CHECKLIST � <br /> � <br /> ; <br /> � <br /> Installation Company Uame and Contact Info:ftla/� /��w��r� �b7� �>�G� i <br /> i <br /> Date Back�vater Prevention device(BWD)was installed:��o�'.� Da,e this torm was completed: Z�G��f I <br /> ( <br /> Inslailation Property Owner Name and Contact Infa. .ie�� /�o�:..��� � � <br /> PropertyAddress:1�j� Lw-��x-�e � <br /> Pre•Installation Inspection Checklfst: � <br /> AI!ifems must be checked'Yes'in order lor a BWD to Ce considered(or instaliatran , <br /> Is there a basemenl or level of lhe house that is at or near assumed sewer main elevation?�1'es ❑No ; <br /> Are there 5xlures in the house localed below the upstream sewer manhole ri�o elevationl�Yes ❑No � <br /> Is the side sewer arrerdly UNPROTECTED Gom se�ver backups(does net have e BWD installed)7 Qj Yes ❑No j <br /> Site Inspection Checklist: i <br /> All items must be checked'Yes'be(ore inspecfron is conside�ed complefe ' ; <br /> Was side sewer N inspected from building lo sewer main? �'�les ❑No CondiGon: <br /> Does side sewer have al least 1%slope from the building lo sewer main? [l�Yes ❑No Descnbe:_ <br /> Have all buiiding sewer drain connections to Ihe side sewer been idenlifed and located7 �Yes ❑ No <br /> Have all property storm drainage connections to lhe side sewer been i�entified and locatedl �Yes ❑No ; <br /> Has property heen evaluated for drainage defdencies wilh findings communicaled to property owner7 �Yes ❑No � <br /> I <br /> Installation Details: ; <br /> What type and brand of BWD was installed at this sit earS Check BVVV, rinder pump,etc.): ; <br /> Where was Ihe device installed (general descriplion,a CB map)7 —�_�Q � � <br /> ��:. �.����'�" �yl i/c voi � r y� . .l , f c .r.-7 Ne �(t � c, r.�.,c' G i <br /> Was lhere any oUier sewer or storm drainage work completed in conjunction�vilh ihe BWO work? Is so please describe _ � <br /> N✓ � <br /> installatlon Checkllst: � <br /> Are all downspouts and site dra�nage disconnected from upstream of lhe 8WD7 �Yes ❑ No Comments: <br /> Does BWD posiliouing meels minimum slope requirement of>1%? [�Yes ❑No Comments: <br /> Can BWD be pulled out for inspeclion and maintenance after loosening thumb screw? �Yes ❑No � <br /> Is BWD locked into the pwper posilion and thum6 screw tightenedl �Yes ❑No ! <br /> Circle the BWD cover:I i ation coverZlandscape a?�/IraKc load bearing cover(drive surface)I access halch(6uilding) <br /> Was property owner shown the location of lhe installed BWD?�Yes ❑ No Comments:_ ! <br /> Property Owner's Signat � Date:2lb IS � <br /> �C���-- Dato: z�S�lS" j <br /> Inslallers Signalur�� <br /> Revision: 2 1 Friday,September 12,2014 ' <br /> i <br /> t <br />