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BACKWATER PREV'ENTION QEVICE FINAL <br />IfVSTALLATION CHECKLIST <br />Cc.en �,:;�+"� c.. <br />installation Company Name antl Contact Info:..1P �i Ki r,P l�Fa�j,� ��+ -�1�� <br />Date Backwaler Prevenlion device (BWD) was installed:�� _ Date ihis form was <br />'L <br />� <br />Installation Property Owner Name and Contacl Info: _�y� �hic-� �n? �- <<<�� <br />Property Address: 1`Y I ot r�lt' <br />Pre•Installation Inspection Checklist: <br />Al! items musl be checked 'Yes' in order (or a BWD to 6e considered for installafion <br />Is there a basemenl or level of the house that ir. at or near assumed sewer main elevation? �es ❑ No <br />Are there fixtures in lhe house located below the upstream sev�er manhole rim e!evaUon? [✓� Yes ❑ No <br />Is the sitle sev�er currenfly UNPROTECTED from sewer bar,kups (does nnt have a BWD inslalletl)? dYes ❑ No <br />Site Inspection Checklist: <br />All items must 6e checked 'Yes' before inspectron is considered co plete /� <br />Was side sewer TV inspected irom building to sewer main? Yes ❑ No ndition: 1.:._�_. <br />Does side sev�er liave at least 1"/o slope from lhe building to sewer main? Yes ❑ No�, /Describe: <br />Have all building se�ver drain connections 10 the side sewer been identified and located? LJ✓ Yes ❑ No <br />Have all property storm drainage connecUoris to the side sewer been idenlified and located? L�es ❑ No <br />Has property been evaluated (or drainage deficiencies with findings communicated io property o�vner? �es ❑ No <br />Installation Details: <br />What rype antl brantl o( BWD was installed al ihis site (Clean Cher,k BWV, Grinder pump, etcJ: G • <br />Where was the device installed (yener�l descripiion, attach map)'? _�(' �z�Ir C M -� ��__j�L�t_(,�— <br />Was ihere any other sewer or stonn drainage work completed in conjunclion with Ihe BWD workl Is so please describe: _ <br />Installatien Checklist: <br />Are all downspouts and site drainage disr.onnected irom upslream of ihe BWD? �'es ❑ No Comments: <br />Does QWD positioning meets minimum slape requirement of >1%? ��Yes ❑ No Comments: <br />Can BVJD he pulled out for inspeclion and maintenance afler loosening ihumb screw? ,[,�Yes ❑ No <br />Is BWD locked into the��r per_posi�ion and ihumb screw tightened? �Yes ❑ Nn <br />Cirde ihe BIND eov �r. irriyatio�er I�u�iscape area) ! traflic load beanng cover (drive suriace)1 ar.cess iiatch (ouilding) <br />Was property o�vner shown the loca�ion of the instailed BWD? ,[� Yes ❑ No Comments: <br />Property Owner's Signature: _ %�-�� Dale: �"�{ /S <br />1 <br />Inslaller's Signaiure: - — -� - Date: �j� � <br />.,� <br />ReviSiqn: 2 ] Friday, September 12, 2014 <br />