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� BACKWATER PREVENTION DEI�ICE FIMAL <br />INSTALLATION CHECKLIST <br />Installatian Company Name and Conlact Info: 0'i%4 �lM� �O � �7- �� q a� z�— <br />Date Backwater Preuention device (BW�) was installed• �3— I� Dale this form was compteted: �°���=� � <br />InslallaUon PropeAy Owner Name and CIonfatct Info: �����- c—� ti� `�� <br />Properiy Address: �n �°i w'�� <br />Pre�lnstallation Inspection Checklist: <br />All items must be checked 'Yes' in order lor a B WD to be cansidered tor instailation ' <br />Is there a basement or level ot lhe house that is at or near assumed sewer main elevation? � res ❑ No <br />Are ihere fixtu�es in ihe house located below the upstream sewer manhole rim eleva6on? �s ❑ No <br />Is the side sewer currenlly UNPROTECTED from sewer hackups (dces not have a BWD instalied)7 [j�-Yes ❑ No <br />Stite Inspection Checklist: <br />All items must he checked 'Yes' 6e/ore inspecfion is cnnsidered complete . f � � <br />Was side sewer TV inspected fram building to sewer main? es ❑ No Condifion: �-� ��� ��`""' ^ <br />Does side sewer have at leas� 1% slope trom the building lo sewer main? [!]Ne� ❑ No Descrihe: <br />Have all building sewer drain connections to Ihe side sewer been idendfied and localed? [�-Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identfied and located? [t�.l'es ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated lo property owne�T [�-Yes ❑ No <br />Installation Delails: C��,� <br />What type and brand of 8WD was installed at this site (Clean Check BWV, Grinder pump, etc.): _ <br />Where was ihe device installed (general description, attach map)? r�—° ° ���'� � <br />Was there any olher sewer or slorm drainaqe work completed in conjunction wilh Ihe BWD work? Is so ptease describe: <br />Insbllation Checklist: p ' <br />Are all downsFouts and sile drainage disconnected (rom upstream of the BWD? es ❑ No Comments: ,�� Y w"'�`` <br />Daes BWD posilioning meets minimum slope requirement ot >i%? [�es ❑ No Commenls: <br />Can BWD be pulled out for inspecGon and maintenance after loosenin�g ,th�u�mb screw? [�'es ❑ No <br />Is BWD locked inlo the proper posifion and lhumb screw lightened? �res ❑ No <br />Circle lhe BWD cover: irtig�6on cov r(landscape a af�/ traffic load b�earing cover (drive surface)/ access hatch (building) <br />Was property owner shown Ihe localion oi ihe inslalled BWD? �'�'es ❑ No Comments: <br />Pmperty Owner's Sign ..�� " _ Dale: -- z v•� r� � <br />InstallersSignalure: Date: C�� ���� <br />Revision: 2 1 friday, Septemher 12, 20]4 <br />