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� BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLA'►ION CHECKLIST <br /> . �-vz�� �#C'',r�. <br /> � <br /> InstallaGon Company Name and Contact Info:djr"r r��r�1 ' � �`�`���F S�'��r! �'�'�'�'�� <br /> Date Backwater Prevention device(BWD)was instalied:���Date this form was completed:��_ <br /> Instailation Properly Owner Name and Contact Info: n ��a � " (' S n d "4�C'�r�7" D��7 <br /> PropeRy Address: � <br /> Pre-Inatallation Inspection Checklist: <br /> All items must 6e checked'Yes'in order for a BWD to be considered for installation <br /> Is there a basa:�ent or level of the house that is at or near assumed sewer main elevation?�Yes ❑ No <br /> Are there fixtures in the house located beiow the upstream sewer manhole rim elevation7�Yes ❑No <br /> Is the side sewer currently UNPROTECTED irom sewer backups(does not have a BIND installed)?�Yes ❑No <br /> Site InspecHon Checklist: <br /> All ifems must be checked'Yes'be%re inspection is considend complete r <br /> Was side sewer N inspecled irom buiiding to sewer main? (�Yes ❑ No Condflion: V�G zr 1 D N` <br /> Does side sewer have at leest 1%slope from the building to sewer main? �Yes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? �Yes ❑No <br /> Have all property stortn drainage conneclions to the side sewer been iden6fied and located7 �Yes ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? �Yes ❑No <br /> Installadon Details: �eC,�� ,l�� <br /> What type and brand of BWD was installed at this site(Clean Check BVNl,Grind�er p_ump,etc.): <br /> Where was the device installed(general description,attach map)? _�,.',P f1.�sJL.Y�� ' ° ^ �� <br /> \ <br /> Was there any other sewer or storm drainage work coR,pleted in conjunc�ion with ihe BWD work7 Is so please describe:_ <br /> ----y--�� �i � (',P�IaCP�_� <br /> � <br /> Installation Checklist: <br /> Are all downspouls and site drainage disconnected from upstream of the BWD? �]( Yes ❑yo Comments: <br /> Does BWD positioning meets minimum slope requirement of>7%?�Yes ❑No Comments: <br /> Can BWD be pulled out(or inspection and maintanance afler loosening thumb screw? �Yes ❑No <br /> Is BWD locked into lhe ro er ' and thumb screw Hghtened? [�Yes ❑No <br /> Circle the BWD co er: irrigalion crover ndsCape area)1 traffic load bearing crover(drive surlace)1 acCess hatch(building) <br /> Was property owner shown ocation of the instalied BWD? �j Yes ❑ No Comments: <br /> Property Owner s Signature� �� _ ./Z6'l� Date: <br /> /� a /� ��� <br /> Installer's Signature: Date: ���a�l� <br /> ��l <br /> Revision:2 1 Friday,September 12, 2014 <br />