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� <br />� <br />BACKWATFR PREVENTION DEViCE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Coi��act Info: h�//ci J�/un�R,h,+����/?S� 3 Ss 7— �So7 <br />Date Backwater PrevenGon device (BWD) was installed: Date this form was completed: <br />Installation Property Owner Name and Conlact Info: /+��q�n w;iScn C�/2S) � 6�s— C�73 �_ <br />PropertyAddress:�3o�/ ��" S1 %�vrsr�f W/f ��uj <br />Pre-I:istallation Inspection Cheeklist: <br />All items must be checked 'Yes' in order (or a BWD to be considered lor installation <br />Is there a basement or level of the house lhat is at or near assumed sevrer main elevafion? j,�,Yes ❑ No <br />Are there fxtures in the house located below the upsfream sewer manhole rim elevation? � Yes ❑ No <br />Is the side sewer currentlyUNPROTECTED from sewer backups (does not have a BWD installed)? �Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked'Yes' be(ore inspecfion is considered cromplete <br />Was side sewer N inspected from building to sewer main9 �Yes ❑ No Condition: <br />Does side sewer have at least t°io slope from the building to sewer main? �Yes ❑ No Describe: <br />Have all building sewer drain conneclions to the side sev�er been idenlifed and locafed? �Yes ❑ No <br />Have all property storm drainage connections lo lhe side se�ver been identified and located? �Yes ❑ No <br />Nas property been evaluated for drainage deficiencies with fndings communicated to property owner? {� Yes ❑ No <br />Installation Detalls: <br />What type and brand of BWD was installed at this site (Clean Check BNN, Grinder pump, etc.): G%�yn a/-, c�,E _ <br />Where was the device installed (generai descriplion, attach map)? <vNYI, Sl�e � L+.riNSP. rn <br />Was there any other sewer or storm drainage work completed in conjunclion �vilh ihe BWD work? Is so please describe� _ <br />Installation Checklist: <br />Are all downspouls and site drainage disconnecled from upslream of the BWD? j� Yes ❑ No Commen4s: <br />Does BW� posilioning meels minimum slope requiremenl of>t%? y�Yes ❑ No Comments: <br />Can BWD be pulled oul for inspection and maintenance afler loosening lhumb screw? (�j es ❑ No <br />Is BWD locked into lhe proper position and thumb screw tightened? [�Yes ❑ No <br />� <br />Circle the BWD cove �� gatitl wver (_ landsc_a_pe.acea}I-iraKc load bearing cover (drive surface)1 access halch (building) <br />Was property owner shown the localio o( the installed BWD? �Yes ❑ No Comments: __ <br />Property Ovmer's Signalu • Date: <br />Installer's Signalure: _ Date: <br />Revision: 2 1 Friday, September 12, 201a <br />