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i <br /> � <br /> I <br /> BACKWA7ER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKLIST � <br /> i <br /> '/ i <br /> Installation Company Name and Conlact Info: �`�l�o ✓Y7 /��iJa�lit q j <br /> � <br /> Date Backwater PrevenGon device (BWD)was installed�,—//,—l�' Datc lhis form was compleled�`�d�lvt`' ; <br /> � <br /> Installation Property Owner Name and Contacl Info: I <br /> Property Address: l�f s� r.J,�},,�.�w,r-P• �r� (,l��, q�or � I <br /> I <br /> Pre•Installation Inspection Checklist: , <br /> Afl ifems rnust be checked'Yes'in order for a BWD to be considered lor installation ; <br /> Is there a basement or level of the house lhat is at or near assumed sewer main elevalion?[�Yes ❑No <br /> Are lhere fixtures in Ihe house localed below ihe upsUeam sewer manhole rim elevalion7�Yes ❑No � <br /> Is ihe side sewer currently UNPROTECTE�from sewer backups(does nol have a BWD ins4�lled)?[,�Yes ❑No � <br /> Site Inspection Checklist: � <br /> i <br /> All items must 6e r.hecked'Yes'before inspecfion is considered compfefe <br /> Was side sewer N inspected from building to sewer main? [�Yes ❑No Condilion: o l� � <br /> � <br /> Does side sewer have at least 1°/a slope from the building lo sewer main? d Yes ❑No Desaibe: i <br /> Have all building sewer drain wnnec6ons to 6�e side sewer been idenGfied and located? dYes ❑No <br /> liave all property storm drainage connections to tne side sewer been identified and localed? [�j Yes ❑�,�N i <br /> Has property been evaluated ior drainage deficiencies�vith findings communicaletl to property owne(? I�Yes ❑No � <br /> Installation Details: i <br /> What type and brand ot BWD was installed at ihis Site(Clean Check BWV, Grintler pump, elc.): �9���AS �3 wV� ' <br /> , <br /> Where was ihe device installed(general description, allach map)? �r�,�.ntain]�'.69 G,�Cd�Gua��� i <br /> I <br /> VJas there any other sev�er or storm drainage work cor,�pleted in conjunc6on wilh Ihe BWD work'7 Is so please describo:_ ' <br /> �� � <br /> � <br /> Installatlon Checklist: ' <br /> Are ail downspouls antl site drainage disr.onne�ted from upstream oi thc BWD? �'S'es ❑No Comments: � <br /> Does BWD posiGoning meets minimum slope requiremenl ni>1%? �Ycs ❑No Commenls: <br /> Can BWD be pulled oul for inspeclion and mainlenance afier lonsening thumb scre�v? [�Yes ❑ No i <br /> Is BVJU locked into lhe proper position and Ihumb scrc�v tiyidened7 [�Yes ❑No � <br /> Circle the BWD cover:irrigation cover(landscape area)!lranc load bearing cover(drive suriace)I access hatch(building) <br /> Was property oH�ner shov:n Ihe locafion of the inslalled BVJD? [�Yes ❑ No Commenls: ; <br /> Property Owner's Signature:�a�.� arr.ni--�y,e, l.a,� Date: J�- y � t �" i <br /> /= <br /> Installer s Signature:���� Dala: �_ — �P-- �r <br /> � <br /> Revision: ) 1 Tucsday,September 7G,)014 � <br />