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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> InstallationCompanyNameandContactinfo: fl/���� l'�unQ.�s ��/ZS� 3Sr7 - /Sc7 <br /> Date Backwater Prevention device(BWD)was installed: ,�(�c�af Date this fortn was completed: 7� �� <br /> Installation Property Owner Name and Confact In(o: !3/��Ce f��,..Gi,� ��5����-o o 6/_ <br /> PropertyAddress: /732 we��ie <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order lor a BWD to 6e considered for insfailation <br /> Is there a basement or level of the house lhai is at or near assumed sewer main elevalion?,��es ❑No <br /> Are there f xlures in the house localed below the upsiream sewer manhole rim elevation7 IJ Yes ❑ No <br /> Is the side sewer curcanliy UNPROTECTED trom sev+er backups(does not have a BWD installed)? - Yes ❑No <br /> Site Inspection Checkllst: <br /> All items musf be checked'Yes'he%re inspeclion is considered complete <br /> 'Nas side sewer N inspected irom building to sewer main? �Yes ❑N,�o Candition: <br /> Ooes side sewer have al least 1%slope from the building to sewer main7 � res ❑N,o_.,�Describe: <br /> Have ali building sewer drain conneclions to lhe side sewer been ide�tif ed and lorated? L'1 Y�es ❑No <br /> Have all property storm drainage connections to the side sewer been idenli6ed and located? L.J Yes ❑�No <br /> Has property been evalualed for drainage deficiencies wilh findings communicated to property ownefl L'J Yes ❑No <br /> Installation DeWils: <br /> What type and brand of BWD was installed at this ' Clean Check BWV �rinder pump,etc.): <br /> Where v�as the device installed(general description,attach map)? � k. , ��r� � � ����� <br /> � P <br /> Was lhere any other sewer or storm drainage work completed in conjunction with ihe BWD work?Is so please describe:_ <br /> N" <br /> Installation Checklisl: <br /> f <br /> Are all downspouts and site drainage disconnecled from upslream ot the BWD?�Yes ❑PJo Comments: � <br /> Does BWD positioning meets minimum slope requiremenl of>1%7 [�'Yes ❑No Commenis: � <br /> Can BW�be pulled out for inspection and mainlenance a(ter loosening lhumb screw? IIYes ❑No <br /> i <br /> Is BWD locked inlo the proper posilion and thumb scre ti htened? �'1'es ❑No <br /> Circle the BWD wv/er� a io�ve andscape are (lratflc�oad beanng cover(drive suriace)1 access hatch(building) <br /> Was property owne�shown th� e ation o(the installed BWD? �Yes ❑No Commenls � <br /> Property0wnersSignat �'Vifll,/ Dale: 1/2a �/,f � <br /> Installcr's Siynature� _ Date: I�ZG�I� <br /> _��� <br /> Revision:2 1 Friday,September 12,2014 <br />