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BACKWA7ER PREVENTIQN DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Instailalion Company Name and Contact Info: _���vvr h r� l! � 4�r �89 �o� z <br />Date Backwater Preven6on device (BWD) was installed: ��I—( �� Date this fortn was camplete�: '� '—! S <br />Instaila�on PropeAy Owner Name and Confact Info: c v 2A-lM2_ �t�-`�-�^^e � <br />Property Address: _i'l. v �I 2Z� � �V� , <br />Prrinstallation Inspectiun Checklist: <br />All items must be checked 'Yes' in order for a BWD ta be cansidered for instellaBon <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? �s ❑ No <br />Are there fixtures in ihe house lo�ated below the upsUeam sewer manhole rim elevatian? es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer baekups (does not have a BWD installed)? [�'Yes ❑ No <br />Site Inspection Checklist: <br />All items m�st be checked 'Yes' 6efore inspection is considered complete <br />Was side sewer TV inspected from building t� sewer main? �❑ No Condi6on: IU e� <br />Does side sewe� have at least 1% slope trom the building to sewer main? [�'�s ❑ No Descnbe: <br />Have all building sewer drain connections to the side sewer been identified and located? [a�(�s ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? �a`es ❑ No <br />Has property been evaluated for drainage deficienc.ies ivith findings communicated to property owne�T �4-1`es ❑ No <br />InstaHation Detefls: � <br />What type and brand oi BWD was inslalled at this site (Clean Check BWV, Grinder pump, etc.): (�� <br />Where was the device instal�ed (general descrip6on, attach map)? � � ✓n � <br />Was there any other sewer or storm drainag� work comple�ed in Gonjunction with ihe BWD work? �s so please describe: ,_ <br />A 1 m,.o — <br />Installation Checklist: <br />Are all downspouls and sile drainage disconnected (rom upstream of lhe BWD? �❑ No Comments: <br />Does 8WD positioning meets minimum slope requirement of >t9'o? �f�s ❑ No Comments: _ <br />Can BWD be pulled out for inspeclion and maintenance aHer loosening thumb screw7 �s ❑ No <br />Is BWD locked into ihe proper position and <br />Circle the BWD cover. irtigation co land <br />Was property owner shown the <br />Property Owner's <br />Insialler's <br />of <br />tightened? �s ❑ No <br />are�/ Uaffic load bearing cover !drive surface)/ access hatch (building) <br />al.el d BWD? es ❑ No Comments: _ <br />Oate: �o" Z � -�J <br />Date: (o , �`� r <br />Revision: 2 �� 1 Friday, September 12, 2014 <br />