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BACKWATER PREVENTIOlV DEVICE F1NAL <br />INSTALLATION CHECKLIST <br />r <br />lrtstaqation Company Name and Contact Info: � C�`�2o PL.v �-► u'3i r.�,� C�..C. �p�i- �¢p •-b 7 2,� <br />Date Backwafer Prevention device (BWD) was installed: ,�~�1 �—/C� �, Date this form was completed; �-/O -�� <br />Installatian Property Owner Name� and Contack Info: _ P�1-�`�Z.t G.� t�'l� C(C� I 1��n �,ti 3(�0 -�.n �'2 ��1 �� i <br />Property Address: 3 3 b�i �Z. v �/c c�2 r¢ v� � VL-�c�� �7'� wra _���d / . <br />Pre-Instal(ation lnspectian Checklist: <br />,411 ifems must be checked `Yes' in order for a BWD fa be considered for installafion <br />Is there a basement or level of the house tha# is at or near assumetl sewer main elevation? � Yes ❑ No <br />Are there fixtures in the hause iocated below the upstream sewer manhole rim elevation? �Yes ❑ No <br />Is the side sewer currently UI�PROTECTED from sewer backups (does nat havs a BWD installed)? �j Yes ❑ No <br />Site {nspection Checklist: <br />All ifems must 6e checked 'Yes' before inspecfion is considered comptete <br />Was side sewer iV irtspected from building to sewer main? � Yes ❑ No Condifion: PGa � <br />Does side sewer have at least 1% slope from the building to sewer main? [�Yes ❑ No Describe: <br />Have afi buiiding sewer tlrain cannections to the side sewer been identified and located? � Yes ❑ No <br />Have alI property storm drainage connections to the side sewer been ide�tified and located? � Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to properky owne�? � Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site Clean Check BWV rinder pump, etc.): <br />Where was the device installed (general descriptio , attach map� <br />Was there any ofher sewer or starm drainage work completed in conjunction with t�e BVIID work? Is sa please describe: �D <br />Installation Checktist: <br />Are all downspouts and site drainage disconnected from upstream of#he BWD? [�Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1 °/4? [.� Yes ❑ No Comments: <br />Can BWD be pulied out for inspection and mainienance after loasenir�g thumb screw? � Yes ❑ No <br />!s BWD €ocked into the propar position and thumb screw tightened? � Yes ❑ IVo <br />Circle the BWD cov : irrigation cover landscape area} !#ra�c load bearing cover (drive surface)1 access hatch (building) <br />Was �roperry owner shown #�e locaiion of the installed BWD? � Yes ❑ No Comments: <br />Property Owner's Signature: �---"�-� �• C' ., Date: 2�- i-�C� <br />Installer`s Signaiure:.__.�_:-��-� Date: 2— S—�� <br />Revisian: Z 1 Tuesday, September 16, 2014 <br />