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B�C�°°CINATER PREVENT[ON DEVICE FINAL <br />,� iNST.ALLAI"I�N CHE�KLiST <br />i�C:�'"� ��e$� ��; f��'i �` �' � �� ��-+� -�'°�.f'e � �� <br />. r..-.� �,.� � > ^'����,� 0 � �i 1 �� �� ) �Gf� " �'i �,� <br />Installafion Cnmpany �Iame and Contact lnfo:�� Y 4�i�r� ��*a��� <br />Date Backwater Prevention device (BWD) was instal[ed_ Date this form was completed: ` <br />Installation Property Owner Name and Contact Info: <br />n r <br />Praper�y Address: <br />0 <br />Pre-Installatian lnspection Checktisf: <br />All items must be checked `Yes' in order for a B WD to be considered for installation <br />Is there a basement ar leve( of t�e hause fhat is at or near assumed sewer main eEev�tion? �'es ❑ No <br />Are there fixtures in the house located below the upstream sewer mar�hole rim elevation? �Yes ❑ No <br />(s the s[de sewer currently UNPR�TECTED from sewer bacicups (does not have a BWD installed}? �!'es ❑ Na <br />Site lnspectian Checklist: <br />C�:.�i_'�� <br />All items must be checked `Yes' before inspection rs consrd�red complete , <br />Was side sewer TV inspected from building to sewer main? es ❑ No Condition: , (�C�7c,1 - <br />a he buildin to se�wer mafn? es ❑ No Describe: <br />poes side sewer have at feast 1/o slope fram t g � <br />Have all building sewer drain canneciians to the side sewer been identifi�ed and Iocated7 �Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and bcated? [�1'es ❑ No <br />Has praperty been evaluated for drainage deficiencies with findings communicated to property owner? [�'es ❑ No <br />lns�allation Details: ' <br />What type and brand af BWD was installed at this site (CEean Check BWV, Grinder pump, etc.}: c� — <br />Where was ihe device installed (general description, attach map}? �_��___ � ��� <br />Was #here any other sewer or starm drainag� work completed in con��nctian with the BWD wark? Is so please describe: , <br />Installation Checklist: <br />Are ai! downspouts and site drainage tlisconnected from upstream of the B1ND? Yes ❑ No Comments: <br />Does SWD pasitioning meets minimum sfape requi�ementof>9%? �]'Yes Na Comments: <br />Can BWD be pulled out for inspectior� and maintenance after loosening thumb screw? �es ❑ No <br />Is BWQ lacked info fhe proper pasition and thumb screw tightened7 �'Yes ❑ Na <br />Cirde ihe BWD cov . irrigation e�er ({and cape area)1 traffic load bearing cover (drive surface} 1 access hatch (�uilding) <br />Was property owner s own the location of the insta(led B1ND? � Yes ❑ Na Comments: <br />Property Owner's Signature: 4��T��a Date: `� �� t <br />Instailer's Signature: � Date: �'� - J� <br />Revision: 2 1 Friday, September 12, 2014 <br />