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�ACkCU�/ATEF� Pi�EVE�T[�N �E\/��E FlN.AL <br />6fU5TALL,AiI�N �HECKLIST <br />�/."�-�t ��.�:F ► � � � . �E ��% <br />� a ��, <br />� <br />Installation Company Name and Contacf Info:�.l � ��`' � � � � � `` �' ' <br />Date Backwater Prevention device (BWD) was insta{led: � Date this form was com <br />, � <br />Insta{lation Property Owner Name and Cantact Info: <br />� y �o�C�. � <br />Property Address �;��� �.,�1Q. � n'� �-���'-� �- <br />Pre-installation Inspection Checklist: <br />A!1 rtems must be checked `Yes' rn order for a B WD fo be consrdered for insfallatian <br />ls there a basement ar leve{ of the house thafi is at or near assumed sewer main eSevation? �'Yes ❑�lo <br />Are there fixtures in the house focated befow the upstream sewer manhole rim elevation? �Yes ❑ No <br />is fhe side sewer currently t1NPROT�CT�D from sewer backups (does nof have a BWD insta{led)? �'Yes ❑ No <br />Site inspection Checkiist: <br />A�1 items must be checked 'Yes' before inspecflon is consrdered camplete �� i <br />Was side sewer �V inspected from bui�ding to sewer main? �'es ❑ No Condition: d <br />Does side sewer have at least 9% slope from the building to sewer main? � Yes ❑ No Describe: <br />Nave ali building sewer tlrain cannections to the side sewer been identified and located? (�Yes ❑ No <br />Have al! prape�ty storm drainage connec�ions to the si�e sewer been identified and located? [�Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to properky owner? � Yes ❑ No <br />{nstallation Details: � <br />What type and brand of BWD was installed at this site (Ciean Check BWV, Grinder pump, etc.}: <br />? �� � C.�,� _ ; S �:�(.. <br />Where was fhe device insta(led (general description, attach map) ., <br />Was there any other sewer ar storm drainage worSc completed in conjunction with the BWD work? Is so please describe: � <br />Installation Checklisi: <br />Are afl downspouts and site �rainage disconnected frorn upsfream of the BWR? �'es ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement ofi>1%? [�es ❑ No Comments: <br />Can BWD be pulled out fior inspection and maintenance after loosening thumb screw? [� Yes ❑ No <br />!s BWD (ocked inta the proper po5ition and thumb screw tightened? �Yes ❑ No <br />Circ(e the BWD cov : irrigation co.�er.. ndscape area)/ traffic load bearing cover (drive su�acej 1 access hatch (building) <br />UVas property awner shown the la ion of e instafled B D? [�'1'es [� No Comments: <br />n <br />Property Owner's Signafure: � ate: •�' <br />Instalfer's Signatur � <br />�---' __ Date: �;�= 6 Y <br />Revision: 2 1 Friday, September 12, 2014 <br />