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BRCKWATER i'REVENTIOiV DEViCE FINAL <br />INSTALLATION CHECKLIST <br />Installalion Company Name and Contacl Info: fiE3a.^. �-=�nl�� a_�e I_��- '�r,c,� -4n�u �-��r2 i <br />Date Back.vater Prevention device �BWD) vras installed:_� -17- IS Date this form e;as completed� 2- { o- �4 <br />Installalion Property O:mer Name and Conta�t Into: D� eoc.K `f�Z�S'- 25�� -t 3 � Y <br />PropertyAddress: 2b��:� Ii'+N Sr L"vt-n--r-r w�. 92 <br />Pre•Installation Inspection Checklist: <br />All ifems musf be checked 'Yes' in order for a BVdD lo be considered for installafiora <br />Is there a basement or ievel of ihe house ihat is at or near assumed se::�er main elevalion? (�, Yes ❑ IJo <br />Are there fixtures in the house located bebw th� upsfream sev�er manhole rim elevation? j�.Yes ❑ No <br />Is tlie side se:ver currently UNPROTECTED from sev;er backups (tloes not have a BWD installed)? i� Yes ❑ No <br />Site inspection Checklist: <br />All items musl be r,Becked'Yes' be(ore rnspection is wnsidered complete <br />Vdas side sewer N insoected from building to sewer main? �Yes ❑ ho Condition: �7� <br />Does side seerer have at least 196 slope irom the building to sev�er mair�9 �j Yes ❑ No Descnbe: <br />Have all building se�r�er drain connections to the side s��ver been identified and located7 I�Yes ❑ No <br />Have all propery sbrm dia�nage connections to the side sev�er 6een idenlified and located? �Yes ❑ PJo <br />Has ,�roperty becn 2valuated for drainage deficiencies v�ith findings communioated to property ovrne�? [k] Yes ❑ No <br />Installation Details: <br />14'hat type and brand of BWD �vas installed at ihis site (Clean Check BWV, Grinder pump, etc.): CLb-qa C�� clC <br />V1�here ivas the device installed (general descriplior�tl ch m p ' <br />�A'as Uiere any other sewer or storm tlrainage work compleled in conjunclion v�ith the BWD �•rork? Is so please descnbe: _ <br />Installation Checklist: <br />Are all doemspouts and sile drainage disconnecied irom upstream of the BWD? � Yes ❑ No Comments'. <br />Does BWD positioning meels minimum slope requiremenl of >1°io? ,�`Yes ❑ No Comments: <br />Can B1ND be pulled out 1or inspection and maintenance afler loosening ihumb scre�v? �Q Yes ❑ No <br />Is BI��D locked into the proper position and lhumb serew tighlened? �( Yes ❑ No <br />Circle the B1ND cover. irrigatien cover (landscape area) I traffic load bearing cover (drive suriace) I access halch (building) <br />VJas property owner shown ihe location of the inslalled BWD? �j Yes ❑ No Comments: _ <br />Property Owner's Signature: (%! /,C��L _ Date: 2'J��"" /�� <br />.�--- <br />Instalier's Signature: _� � Date: Z--�- (� - I� <br />Revision: 2 1 Tuesday, September 16, 2014 <br />