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1 <br /> �,�Cf�UVA��R d��E�4�NT10R� �E�lCE FlhlA� ; <br /> d ENST'ALLA�'I��1 CFlEC�L.IST � <br /> i <br /> ��r� c�tin �x:p�-�� � ���de 5c��.�r-, L z.� � <br /> Ins(all2tion Company Name antl CoNact Info:.�� � �rP (4.�-� ��{4-C�;����i r'Y•1, ��`�i�)'��fC� .�/_'�;� i <br /> I <br /> Date Backwater Prevention de��ice{BWD)v�as installed:�(��s Date this form was completed: , � <br /> Installation Property Owner Name and Contacl Info:� �1 "����`'� I <br /> PropertyAddress: .� �- �J � �-U 3 <br /> Pre-Installation Inspection Checklist: ' <br /> A!!items must be checked'Ves'in order for a BWD to 6e considered/or insfallation <br /> Is there a basement or level of the house that is ai or near assumed sev�er main elevation? [�Yes ❑ No : <br /> Are Ihere fixtures in the house located below(he upslream sewer manhole rim elevation? [�Yes ❑ No i <br /> Is fhe side sev�er currently UPIPROTECTED from sev�er backups (does not have a BWD insfalled)? �]'Yes ❑ No � <br /> Site Inspection Checklist: � <br /> i <br /> All items must be checked 'Ves'be(ore inspection rs consrdered complete I ; <br /> Was side sevrer'�V inspeoted from building to sewer main? �Yes ❑ No Condilion:_ �i �d <br /> Does side se�ver have at least 1%slope from Ihe building lo sewer m2in? �Yes ❑ No Describe: <br /> Have all building sev�er drain connections to the side sev�er been identifed and locafed? �Yes ❑No � <br /> Have all property storm drainage connections to the side sewer been identified and located? [�Yes ❑ No � <br /> Has property been evaluatetl for drainage deficiencies with findings communicated to property ownef? [�i'es ❑ No • <br /> � <br /> Installation Details: <br /> What type and brand of BWD was inslalled at ihis sile(Clean Chedc BINV, Grintler pump, etc.): 'a ��� <br /> Where was�he device insfalled (general descripfion, atfach map)? ��P �? �"�'C'�c� �S ('�a �- <br /> � <br /> Was lhere any other se�ver or storm drainage�ti�ork completed in conjunction v�ith the BWD r�ork? Is so please describe:_ ; <br /> _ ��,n -e ; <br /> Installation Cliecklist: <br /> Are all downspouts and site drainage disc.onnected from upstream of the 8WD? �Yes ❑ No Comments: _ � <br /> Does BWD posilioning meets minimum slope requiremenl of>1°07 �]Yes ❑ No Commenis: � <br /> Can BWD be p�lled out for inspection and maintenanee after loosening thumb screv�? (�Yes ❑ No � <br /> i <br /> Is BWD locked into the proper position and thumb scre!v tigh(ened? }�Yes ❑ No � <br /> Circle ihe BWD co er: irrigation.cover la�idscape area)I traffic load bearing cover(drive surface)I access natch (building) <br /> Was properly owner shovdn the loeation of lhe installed BWD? Yes ❑ No Commen(s: ; <br /> 9 ` <br /> Property Owner's Signature: �Q Uate: � i <br /> Inslaller'sSignature��. ��,. - v Dale� L�"' �� � l�_ � <br /> C_/ `� <br /> Revision:2 1 Friday,Sep[ember 12,2014 ! <br /> I <br /> � <br />