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- � , � � � � � ;�. � <br />. 1: . <br />INSTALLATI�N CIHEC�CLIST <br />�'Y�'',('"b �L�Z� ��'� i � "f' '� iC.� ��-��-��'�'l G �C.1 <br />fnstailation Company Name and Contacf lnfo:,�� �� �i �.C�; f4��-�,� -��� �� -�i �r1�� (-�:�„):�1��t.7 �- �l'.���,,.�"� <br />a — <br />Date Backwater Prevention device (8WD) was installed: � Date ihis form was completed: <br />Installation Properfy Owner Name and Contact fnfo: �,���y �,� ,i.�_ ��S ��', �7 � --�U � �. <br />Property Address; '?�"�' 1`� J� ��--•�� V A p �L g�� � <br />Pre•Installatian lnspecfion Checkfst: <br />A11 ifems musf be checked `Yes' in order for a BWD to be considered for installafion <br />Is #here a basemenf ar levei of fhe hause thaf is at or near assumed sewer main elevation? [�'Yes ❑ No <br />Are there fxtures in the house located below the upstream sewer manhole rim elevation? �Yes ❑ No <br />Is the side sewer currentfy UNPROTECT�D fram sewer backups (does not have a BWD installed}? �Yes ❑ No <br />Si#e lnspectian Checklisf: <br />Al1 rtems must be checked `Yes' before inspecfion is considered camplete <br />Was side sewer TV inspected from building to sewer main? [�'1'es ❑ No Condifian: �� <br />Does side sewer have at least 1% slope from fhe building to sewer main? �`es ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and �ocated? �'Yes ❑ No <br />Nave all property storm drainage connections to the sitle sewer been identified and located? [�fes ❑ No <br />Nas property been evafuated for drainage deffciencies with findings communicated to property owner? �Yes ❑ No <br />Installation Detaifs: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): ����--� <br />Where was the device instalied (general description, attach map)? ��'�����_�c"�L4.�_,� ��t-�- <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD wark? {s so please describe: _ <br />t`� <br />Installation Checklist: <br />Are all dawnspauts and site drainage discannecfed from upstream of the BUVD? �es ❑ No Comments: <br />Daes BWD positioning meets minimum sfope requirement af>1%? �P'es ❑ No Comments: <br />Can BWD be pulled out for inspection and ma€ntenance a�ter laosening thumb screw? �r'es ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? ,�Yes ❑ No <br />._ ... ...... ... .. .. . .... <br />Circle the BWD co r: irrigatio v�r- dscape area) I traffic load bearing cover (drive surtace} I access hatch (bui{ding) <br />Was property owner shown the location of the instalfed BWD? �Yes ❑ No Comments; <br />Property Owner's Signature: lit LL � Qate:t4 �/%—/L� <br />._...� . � �. %� �,� <br />Installer's Signature: --� - - � Date: �' <br />Revisidn: 2 ,� 1 Friday, September 12, 2014 <br />