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�AC�"CW,�TE� PI�EVE[VTION DE1/�CE FlNAL <br />� INST'e4LL�►1"I�N CHE��CLI�i <br />�1��'a ���a� ���4 �.� �i- � �t� �Cx. ��—.�"� � t�.� <br />Instaffation Company Name and Cantact 1nfo:�� �'� i � f��7���5��'�-�►►'l�� ���� :��s" ."���� <br />Date Backwater Frevention device (BWD} was insta!{ed: Date this form was comple#ed: <br />, __ <br />(nstallation Proper�y Owner Name and Contact Info: <br />Property Address: t� ?.�� � l�� <br />Pre-Installation Inspection Checklist: <br />Afl items musf be checked `Yes' rn order for a BWD to be consrdered for installafron <br />�..�,,.,� <br />Is there a basement or level of the house thai is at or near assumed sewer main elevation? �Yes ❑ No <br />Are there fixtures in the house iocated beEow the upsfream sewer manhole rim elevation? �'Yes ❑ No <br />ls the side sewer currenffy UNPROTECTED from sewer bac�Cups �does not have a BWD insfalfed}? �'Yes ❑ No <br />Si�e In�pection Checklis#: <br />A�1 ifems must be checked `Yes' befare inspecfion is considered compJete <br />Was side sewer TV ins ected from building to sewer main? Yes ❑ No Condition: ��,.��� <br />P � <br />Qoes side sewer have at least 1% sfape from fhe building to sewer main? �es ❑ f�o Describe: <br />Have al{ building sewer drain connections to the side sewer been identi#ied and located? �Yes ❑ No <br />Nave all property storm tlrainage connections to the side sewer been identified and located? �Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property awner? �'es ❑�lo <br />Insta(lation Defiails: <br />What type and brand of BWD was instalted at this site (Clean Check BWV, Grinder pump, etc.); �� <br />�. <br />Where was the device instal3ed (generaf descriptian, attach map}? _ <br />Was there any other sewer or storm drainage work compfeted in conjunctian with the BWD work7 Is so please describe: ^, <br />lnstallation Checklist: <br />Are all dawnspouts and site tlrainage discannected from upstream of the BUVD? �►'es ❑ No Comments: <br />Does BWD pasifioning meets minimum slope requirem�nfi of >1°!0? �'Yes ❑ No Comments: <br />Can BWD be pulled out for inspectian and maintenance after laasening thumb screw? � Yes ❑ No <br />Is BWD lacked into the pro�er position �nd thumb screw tightened? �1'es ❑ No <br />__._...__.._....,� __.._..._--- __..._.. <br />Circle the BWD co r�irrigat'on�cover (fan cape area) / traffic loatl bearing cover (drive sur�ace) ! access hatch (buiiding) <br />Was propertv owner shawn the location of the installed BIND?�Yes ❑ Na <br />Property Owner's Sig <br />Installer's Signature: <br />Revision: 2 <br />Comments: <br />Date: � r ` <br />� <br />Date: <br />iay, September 12, 2014 <br />