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� <br />� <br />� <br />'" i�i' �' '� � � ` <br />i <br />INSTALLATItaN �CHECKLIST <br />Installaiion Company Name and Contact Info: �Y���� ����o,���rrz� <br />Date Backwater Prevention device (BWD) was installed: R�r''�! �` � Date this form was completed: ,���,�w�-'� <br />installation Property Owner Name and Contact Info: ,-�✓4 d��� h'��15� <br />Property Address: , i _�_/�'_�"' ���i� <br />Pre-Instalia#ion Inspection Checklist: <br />All items must be checked `Yes' in order for a BWD to be cansidered for insfallation <br />Is there a basemeni or level of the house that is at ar near assumed sewer main elevation? � Yes ❑ No <br />Are there fixtures in the hause focated below the �pstream sewer manhole rim elevation?�] Yes ❑ No <br />� Is fhe side sewer currently UNPROTE�TE!] from sewer backups (does nat hav� a BWD installed}?� Yes ❑ No <br />Site Inspection Checklist: <br />Ali rtems must be cheGked `Y�s' before inspecfion is cansidered complefe <br />Was side sewer N inspected from building to sewer main? � Yes ❑ No Condition: � <br />Does side sewer have at least 1% slope from the building to sewer main? r� Yes ❑ Na D�scr�be: <br />Have ali building sewer drain connections to the side sewer been identified and located? � Yes ❑ No <br />Have all properky storm drainage conneciions to the side sewer been identified and focated? Q Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? � Yes ❑ No <br />� <br />lnstallation Details: <br />What type and brand of BWR was installed at #his site (C�`an��heck B� Grinder pump, etc.): <br />�a _.______. �____._ <br />Where was the device installed (gensral description, attach map)? 3���� �.c�F , .���.r�.�.� �-�� <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: � <br />�a�� <br />Installation Checklist: <br />Are all downspouts and site drainage discorrnected fram upstream of the BWD? �j Yes ❑ No Comments: <br />a <br />Does BWD positioning meets minimum siope requirement of >1 %? C� Yes ❑ No Comments: <br />Can BWLI be pulled aut for inspection and maintenance after loosening thumb screw? ,�f Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? [� Yes ❑ No <br />Circle the BWD cover. jtcig�fio�S o er an�� �axea}f #ra�ic load bearing cover (drive surfiace)/ access hatch (building) <br />c...�....�.�.��,-.— <br />Was property awner shown the location of the installed BWD? � Yes ❑ No Comments: <br />r-' <br />Jl1, �,,,� ,,, <br />f�- <br />Property Owner's Signature: `%`'j �-�.�"',�� l��—�.- Date: ��-.�,��..s'"` <br />Installer's Signatur . �,.s''� Date: _ �`�'��%_5" <br />itevision: 2 `''`��'"� ""� .`" Friday, September 1Z, 2014 <br />