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; <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> INSTALLATION CHECKLIST ! <br /> , <br /> � <br /> � �i cun �� � G �r �� . }.��'� � �c � <br /> Installation Company Name and Contact Inin:��Tl • � [f,��;),-�q4��Sj; (1�l,i,L (-�,x �� •�� i <br /> - �--��� )' IQ � <br /> Date Backwater Prevention device (BWD)eJas installed�-(��- Date this form was ccmpleted:�,�` R <br /> I <br /> Installation Property Owner Name and Contacl Info: �,�s ��/ �� ,�/' � ,{� /�.��" ���0�� <br /> f—�'--b��'JL��` -l�_I�� 1 I <br /> PropertyAddress: c��7��=��� �- �JEpn�� Ox',,l.p� : <br /> Pre.lnstailation inspection Cher;iciist: t <br /> All rtems must be checked'Ves'in urder for a 8WD to be consitlered for rnstal/ation ' <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation? �Nes ❑ No � <br /> Ara there fixtures in the house located below the upslream sewer manhole rim elevation?�1'es ❑ No ' <br /> Is fhe side sewer currently UNPROTECTED from sewer backups (does not have a B�ND installedJ?�es � No � <br /> Site Inspection Checklist: � <br /> All items must be checked'Yes'before inspectian is considered complete � <br /> Was side se�ver TV inspected from building to sewer main? �es ❑ No Condition: �� <br /> Does s�de se�ver have at least 1%slope from lhe building io sewer main? �(es ❑No Describe: ; <br /> Have all building se�ver drain connections to the side setiver been identified and located? �es ❑ No � <br /> Have all property storm drainage connections to the side sewer been identified and located? �s ❑No ' <br /> Has property 6een evaluafed for drainage deticiencies with findings cornmunicated fo property owner% �yes ❑ No � <br /> Installation Details: � <br /> � /) � <br /> What rype and brand oF BWD�vas installed at this site(Clean Check BWV, Grinder pump,etc.): � <<�.e,(i : <br /> Where�vas the device instailed (generai description, attach map)? �P�' r��u�� �-t� I�' � �L � <br /> �IA��L : <br /> i <br /> Was there any other sewer or storm drainage U�ork completed in conjunction with the OWD work? Is so p�ease describe: ! <br /> Installation Checklist: ��rn�j � <br /> Are all downspouts and sile drainage disconnecfed from upstream of the BWD^ �'Yes ❑ No Comments: ; <br /> Goes 8WD positioning meets minimum slope requirement of>1%? [�'es ❑ No Comments: ' <br /> Can BWD be pulleo oul far inspeciion and mainlenance after loosening thumb screw? �,'es ❑ No ; <br /> Is BWD locked into the proper position and lhumb screw 6ghten�d? �Yes ❑ No � <br /> Circle the BWD cov . ' ngafion c erjfa"n ape area)/traffic loari bearing cover(drive surface)/access hatch(building) <br /> N.'2s property own wn the location of the installed B�ND? � es ! <br /> °' ❑ No Commenis: <br /> � <br /> Property Owner's Signature: � j <br /> - Date:�1,� _ � <br /> Installer's Signatur � �-- ' <br /> Date: 0 Z.l y <br /> Revision:2• 1 � Friday,September 12, 2014 � <br /> I <br />