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BACKUVATER PREVENTION DEVICE FINAL <br /> d INSTALLATION CHECKLIST <br /> Installation Company I:ame and Contact Into: <br /> Date backwater device (BWD)was installed: — —/ / Date this form was completed: �/,3 —/,� <br /> �— <br /> Inslalialion Property Uwner Name and Contact Info: _ <br /> Property Address: ���1D �_.7 '_ . 5� <br /> Pre•Installation Inspection Checklist: <br /> AI!ifems rnust be checked'Yes'in order for a BWD to be considered for installation <br /> Is there a basemenl or level of ihe house lhat is al or near assumed sew.er main elevalion? [�Yes ❑No <br /> Are there fixtures in Ihe house located below ihe upstream sewer manhole rim elevatior.?�] Yes ❑No <br /> Is Ihe side sew:r currently UNPROTECTED(rom sewer backups(does not have a BWD installed)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'belore inspeclion is considered compfete <br /> Was side sewer N inspected from building to sewer main? �]Yes ❑No Condition: <br /> Does sitle sewer have at leasl 1%slope(rom the building to sewer main7 [�Yes ❑ No Describe: <br /> fiave all building sevler drain connections to the side sewer been identified and located? �Yes ❑ No <br /> Hav�.all property slorm drainage connections to lhe side sewer been identified and located7 � Yes ❑No <br /> � Has property been evaluated for drainage deficiencies wilh fndings communicated to property owner? �Yes ❑ No <br /> Instaliation Details: � � <br /> Whal type and brand of BWD was installed at this sile(Clean Check BWV, Grinder pump, etc.): . <br /> 4Uhere�vas the device installed(yeneral description, altach map)? �'S �� �6��',�tQ� � <br /> Was there any other sewer or slorm drai�e wp�k completed in conjunclion wilh the ARWD work7 Is so please describe; <br /> Installation Checklist: 7/ <br /> Are all downspouts and sile drainage disconnected from upstream of the BWD7 �Yes ❑ No Comments: <br /> Does BWV posilioning meet minimum slope requirement of>1%? � Yes ❑ No Comments: <br /> Can BWV be pulled out for inspeclion and maintenance after loosening t mo screw� �Yes ❑No <br /> is �WV locked into the proper posilion and thumb screw tightened?�es ❑ No <br /> Circle the BU1N cover irrigation cover(landscape area)1 traffic lo d bearing cover(drive suriace)!access hatch(building) <br /> Was homeowner shown ihe lo tion of the inslalled AB�VD? Yes ❑No Comments: <br /> �( Property Owner's Signature: Date: � — �'l"�S <br /> ! �` Installer's Signature: Date:���_ <br /> Revision: 2 1 Thursday, October 02, 2014 <br />