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BACKWATER pREVENTION DEVICE FINAL <br /> INSTALLA i ION CHECKLISS <br /> �:t�� �+�'�,��j; <br /> P Y A.t�c� �_� 71�E 7�"i.iY.I,� �.L f�f'L:::,�=IC}".�iW1 <br /> Installation Com an Name and CoNact Info: u�� � � ��F1� <br /> Date Backwaler Prevention device(BWD)was installed:��_Date this form was completed: lal4l�4 <br /> Installation Property Owner Name and Conla�Info:T/"rI °I'�(ll"1 ��Yl r-�-�'1 � �aS-����1-�c+0�o� <br /> Property Address: � I� I I.t�-�Yr�v'P A-r�� '—�>1` Q��n� <br /> , <br /> Pre-Installation InspecUon Checklist: <br /> All items must 6e checked'Yes'in order for a BWD to 6e considered for installation <br /> Is there a basement or level of the house ihat is at or near assumed sewer main elevation7�Yes ❑No <br /> Are there fixtures in the house located below the upsiream sewer manhole rim elevation?�Yes ❑ No <br /> Is the side sewer currenlly UNPROTECTED from sewer backups (does not have a BWD installed)?�Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'be�ore inspection is considered complete <br /> Was side sewer N inspected irom building to sewer main? �Yes ❑No Condition: rGr� � <br /> Does side sewer have at least 1%slope irom the building to sewer main? �Yes ❑No Describe: <br /> Have all buiiding sewer drain cronnecl�ons to the side sewer been identified and located? �,Yes ❑No <br /> Nave all property storm drainage conne�tions to the side sewer heen identified and located? �Yes ❑ No <br /> Has property been evaluated ior drainage deficiencies with findings communicated to property owner? �Yes ❑ No <br /> Installation Details: n /� <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): fSFC'�Y' �°�l V <br /> Where was the device installed(general description,attach map)? ,5�' /Y��Ct!'�;iQ�� � �'b .0 � <br /> Was there any other sev�er or storm drainage worlc completed in conjunclion vdih the BWD work?Is so please descnbe:_ <br /> f�CSYI_Q <br /> InstallaUon Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? �Yes ❑ No Commenis: <br /> Does BWD positioning meels minimum slope requirement of>1%? �Yes ❑No Comments�_ <br /> Can BWD be pulled out for inspection and mainlenanr.e after loosening ihumb scre�v? �]Yes ❑No <br /> Is BWD locked into the proper position and thumb screw tightened? �Yes ❑No <br /> Circle the BWD cov :iRigaUon cov�andscape area)I tra�c load bearing cover(drive surtace)1 access hatch(building) <br /> Was property owner shown Ihe localion of the installed BWD? [�Yes ❑ No Comments: .__ <br /> �� � � /Z -�?- i `/ <br /> Property Owner's Signature: C��` ' __ _ Dale: i <br /> InslallersSignahire: � Date:� ' j <br /> Revision:2 1 Friday,September 12, 2014 <br />