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/r _. <br />��� <br />� <br />�Ac�cw�r�� ��Ev��Trorv ��v�c� Fe��� <br />�NSTALL�►iI�N CHECKLI�T <br />u°�i'"� �c�� �=��'� �� �` � � �C-� -��-�"`L �.- �a..� <br />[nstaElation Company Name and Contact Infa��� �4''� � .C; .�� � � � � p ` - =' � �� �` � - � <br />Date Backwater Prevenfiion device (BWQ) was insta[led; �',� Date this form was completed: � <br />Installation Property Owner Name and Contact Info: ,� '�1� �,��..�,�,���,���-�..- <br />Praperty Address � �i�?� (�,1"x (C Pf� �`t � � � t��'�:� � ���� i <br />Pre-fnstaliation Inspect�on Check[ist: <br />All rtems musf be checked `Yes' rn order for a BWD fo be considered for insiallafion <br />Is there a basement ar leve{ of the house thaf is at or near assumed sewer main elevatian? [� Yes ❑ No <br />Are there fixtures in tF�e house lacated below the upstream sewer manhofe rim elevation? �Yes ❑ No <br />[s the side sewer currently UNPROTECTED fram sewer backups (does not have a BUVD insta�led}? � Yes ❑ No <br />Site Inspection Checklist: <br />A1f ifems must be checked `Yes' before inspectron is consrdered complefe <br />Was side sewer TV inspected from building to sewer main? �Yes ❑�io Condi�ian: l G�� <br />�]oes side sewer have at leasf 1% slope from the building ta sewer main? �1'es ❑ No Qescribe: <br />Have all building sewer tlrain connections tQ the side sewer been iden#ified and locafed? � Yes ❑ No <br />Have afl properky storm drainage connections to the side sewer been identified and located? [�es ❑ No <br />Has property been evafuated for drainage deficiencies with findings communicated to property owner? �Yes ❑ No <br />�ns�allation Details: r �1 <br />UVhat type and brand of BWD was instalfed at this site (Clean Check BWV, Grinder pump, etc.): _ K� "`' ^ nJ <br />Where was the device installed (general tlescription, attach map)? _�.��._(�'�itc�'� ., -�.� � ��" <br />Was there any other sewer or storm drainage work completed in conjunction wi#h fhe BWD wark? Is sa please describe: _, <br />�.� �r� <br />lnstallation Checklist: <br />Are all downspauts and site drainage disconnected from upstream o# the BUUD? �(es ❑ No Comments: <br />Does BWD positioning meefs minimum slope requirement of>1%? �es ❑ No Gomrnents: <br />Can B1ND be pulled aut for inspection antl maintenance af�er foosening thumb screw? �'es ❑ No <br />Is BWD focked into the proper posi an and thumb screw tightened? �'es ❑ No <br />�-_, .. _ . , <br />Circle the BWD c�u�-, irrigation co�r,�la��iscape area) /traffic load bearing cover {drive surta�e)1 access hatch (building} <br />UVas property owner shown the lo <br />Property Owner's Signature: <br />Installer's Signature: <br />the ins# Iled BW es ❑ No Comments: <br />. ' 4/alE. ��r � <br />Date: � � ✓ " 1 � <br />Revision: 2 � � �- Friday, September 12, 2014 <br />