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i <br /> BACKWA�tER PREVENTION DEVICE FINAL ; <br /> INSTALLATION CHECKLIST <br /> ��r�c�ti n ��.� �G ^'r �.i� e.cc�'� L L-G ' <br /> Installation Company Name and Contacl Inio:S��r Q�CN 14�ti,�` ' '��S�J�n�'F'rl� a' �)'N��;� <br /> L�ate Backwater Prevention device(BWD�was installed:,�.�(�f,�_Date this form tivas compleled: aG�� <br /> Installation Property Owner D:ame and Coniact Info: V'" i <br /> Property Address: � 7� 7' "� <br /> Pre-Installation Inspection f.hecklist: <br /> All items mosl be checkad'�es'in order(or a BWD to 6e conside�ed for insfalfation <br /> Is ihere a basement or level of the house that is at or near assumed sewer main elevalion? �Yes ❑No <br /> Are there fixtures in Uie house localed below the upstream ser�er manhole rim eleval�on?� Yes ❑No <br /> Is the side se�t�er curcenlly UNPROTECTED(rom sewerbackups (does not have a BWD insfalled)7 �Yes ❑ No <br /> Site InspecUon Checklist: I, <br /> All items must 6e checked'Yes'be/ore inspection is considered compfete <br /> Was side sewer 71�inspecled from buildiny to sewer main? [�Yes ❑No Conditiorc �n[�d — <br /> Does side sewer have at least 1%siope irom Ihe building So sewer main? �Yes ❑No Describe: <br /> Have all building sewer drain connections to the side se�t�er been identfied 2nd located? �Yes ❑No <br /> Have all property storm drainage conneclions to the side sewer been identified and localetl? (�Yes ❑ No <br /> Was property been evalualed(or drainage deficiencies with fndings communicated to properiy owner? �]Yes ❑No <br /> Inst�°ation Detafls: �� -�__,.,, �-„ n <br /> W� pe and brand of BWD was inslalled at ihis site(Ciean Check B1NV,Grinder pump,etc.): , .�ii�1_—�s.�.�c=�, r - <br /> Whore was ihe device inslalled (general description,altach map)? �(��. f-���n C�y—L�—�-�-��-� <br /> Was there any other sewer or slorm drainage work completed in conjunclion wi�h lhe BWD work7 Is so plense describe:_ <br /> ��Y�� � <br /> Instaliation Checklist: ! <br /> Are all downspouls and site drainage disconnected from upsiream of Ihe EiVJD? �Yes ❑No Comments: ; <br /> Does BWD positioning meets minimum siope requiremenl ot>t%? �.Yes ❑No Commenls:_ � <br /> Can BWU be pulled out for inspection and maintenance after lonsening Ihumb screw? �Yes ❑No <br /> Is BWD locked into Ihe proper ppsition and ihumb screw tightened? �Yes ❑Na <br /> C �le lhe BWD cov r.irrigation cover�(la�dscape area)i Irafiic load bearing cover(drive surface)!access hatch(building) <br /> Was{.�operty owner shoavn the IoraUon of the installed BWD? �'es ❑No Comments� . <br /> Property Ovmer's Signature: � � /z�'�"`'` Dale: .� �•�- �_— <br /> Insialler's Signature: ��Gl' Dato: � a �(� <br /> Revision:2 1 Friday,September 12,201M1 : <br />