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_ BACKWATER PREVIENTION DEV;CE FINAL <br /> INSTALLATION CHECKLIST <br /> � l'►"lEf i Ccid'1 � �G ^Y �;� . �.ci-�'! L L� <br /> Installa6on Company Name and Conlact Into:5��;�' �i .(? •��);�+-L�5<�n..i rrl�(,�?Gz):�r.��l� <br /> Dale Backwaler Prevention device(BWD)vaas ins(alled: �7 (o Date ihis torm�vas completed: '7 J <br /> Installation PropeRy O�:+ner Name and Contact Inio: �QSP =-r,Y1�l�����7 � �3�7- �'`i��a <br /> Properly Address: GZ� � I.�� ��'• `�=JP/LG.�" q,c�� � <br /> Pre-(nstailation Inspection Checklist: � <br /> All items must be checked'Yes'in o�der(ora BWD to 6e considered forinsfallalion <br /> Is there a basement or level of the house lhat is at or near assumed sewer main elevation? [�Yes ❑ No <br /> Are tnere fixlures in the house looaled below the upstream sewer manhole rim elevation?�Yes ❑ No <br /> Is the side sewer currently UNPROTECTED hom seU�er backups(tloes not have a BW�insfalled)?�Yes ❑ No ' <br /> � <br /> Site Inspe�tion Checklist: <br /> I <br /> All ifems must be checked'Yes'before inspecfion is considered complete � <br /> Was side sewer TV inspectetl irom building to sewer main? [`�Yes ❑ No Condition:___��.�__ � <br /> Does side sevrer have at least 1%slope irom the builtling to sewer main? �-Yes ❑No Descri6e: + <br /> Have all building sewer drain connections to the side sevrer been identi5ed and lo�zled? �Yes ❑No <br /> Have all property storm drainage cor.nections lo the side sewer been idenlified and locatcd? �Yes ❑ No 1 <br /> Has properfy been evaluated(or drainage deficiencies wilh findings comnunicafed to properfy owner? �Yes ❑ No � <br /> � <br /> � Installation Details: �i <br /> � What type and brand of BWD evas installetl al Ihis site(Clean Check BWV, Grinder pump,etc.): G Z �p i <br /> Where was tho devir,e instal!ed (general description,attach map}? �� e��(��Cl /-1 S Yr,(�[.t_�,�t- � <br /> � <br /> � <br /> Was ihere any other seerer or storm drainage work completed in ccn unclion with the BWD work7 Is so please describe:_ � <br /> � -- ----- --- ----- -���---- <br /> Installation Checklist. � <br /> Are ali downspouls and site drainage disconneeted from upstream of the BWD? ��(es ❑ No Comments: � <br /> � <br /> Uoes BWD positioning meets minimum slope requirement of>1%? �"Yes ❑ No Commenls: <br /> Can BWD be pulled oul(or inspection and maintenance afler loosening ihumb scr�w? �es ❑ No ' <br /> Is f3WD locked inlo the rnper_pqs_ition and ihumb screw tighlened? �Yes ❑ No � <br /> Circle lhe BWD cou irngalion cover(I dscape area)/iraf(ic load bearing cover(drive surface)1 access hatch (huilAinr�) � <br /> �� <br /> Was property owner sholvn the loca n of the installed BWD? �J'i'es ❑ Ro Comments: <br /> Properly Owner's Signa Eirt e: � c---- Date: � o� / $ I <br /> 1 <br /> � Insialler's Signalure: Date: 7 l <br /> I <br /> Revision:2 1 Friday,Septemher 12,2014 I <br /> ! <br /> � <br /> I <br />