Laserfiche WebLink
�iaCF(WATER PFtEVENTION DEVICE FIIVAL <br />iNSTALLATIAIV CHEC�CL.15T <br />Cc�z <br />Installation Company Plame and Conlact Info:Jr�s <br />Date Backwate� Prevention device (BWD) was inslz <br />Installation Property Owner Name and Contacl In(o: <br />Property Address: 1 ���a ��'1 � ��� <br />� <br />Date this form was <br />�L <br />Pre-Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fa a B WD to be considered for inslallation <br />Is there a basement or level of the house that is at or near assumed sevaer main elevation? [�Yes ❑ No <br />Are there fixtures in the house located below the upsiream sewer manhole rim elevation? [� Yes ❑ No <br />Is the sitle sewer currenlly UNPROTECTED irom sewer backups (does not have a BWD insialletl)? [�S'es ❑ No <br />Site Inspection Checklist: <br />All items musf be checked 'Ves' Aafnre inspection is c�msidered complefe /� <br />Was side sewer TV inspected trom 6uilding lo sev�er main? �Yes ❑ No Condition: (�l c0. <br />Does side sewer have al least 1% slope irom ihe huilding to sewer main? [� Yes ❑ No Descrihe: _ <br />Have all building sewer drain connections to the side se�ver been identified and located? [� Yes ❑ P:o <br />Have all property storm drainage conneclions to the side sewer been idenlified and located? �� Yes ❑ No <br />Has properly been evaluated for drainage deficiencies wilh findings communicatetl to property owner? �'es ❑ iJo <br />Installation Details: <br />Whai type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): �y�`'' � <br />Where was Ihe devicr. inslalled (general tlescription, atlar.h map)? ����`�`�.�.� �/��� � <br />Was Ihere any other sewer or storm draina,ye work compleletl in conjun�lion w}ti tl^e BWD work7 Is so please describe: _ <br />Installation Checklist: <br />Are all dotivnspouts and si�e drainage disconnected from upstream of the OWD? � Yes ❑ No Commenls: <br />Does BWD posilioning meels minimurn slope requirement of >1 °/a? �Yes ❑ No Commenls: <br />Can BWD be pulled oul tor inspection anri maintenance after loosening thumb screw? �Ps ❑ No <br />Is BWD locked into the pro��:r �,osition and thumb screw tiyhtenetl? �,,#'Yes LJ No <br />Circle the DWD r,ove ' ir�gatian covcr I adscape area) I Iraffc loatl �earing cover (drive surface} 1 ar.cess hatch (building) <br />Was property otvner shown the location of the inslalled BWD'? �Nes ❑ No Cor�menls: <br />. � <br />Property Owner's SignaWre: _ � L<��� <br />Dale: �� Z� ' �� <br />Insfaller's Signalure: _� � _� _ ` _---.. Da�e:1 <;i � <br />Revision:? 1 Fiiday, September]2, 7074 <br />