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- �AC�iVI►ATER PREVENTfON DEVICE FIt�AL <br />INST'ALLAiION CHEG�iLIST . <br />(nstallation Company Name and Contact Info: <br />�� <br />� <br />Qate Bac{cwater Prevention device (BWD) was instalfed: -�—� Date thfs form was compieted: �-`7 "`S <br />Installation Proper�y �wner Name and Contact lnfa: � ' ��- <br />Property Address; �-- <br />Pre-Installation inspec�on Ch�ckiisi: <br />All ifems must be checked `Yes' in order for a BWD to be considered for installation <br />is there a basement or level of the house that is af or near assumetl sewer main efevaiian? [�] Yes ❑ No <br />Are there fixtures in the house located be(oav the ups#ream sewer manhole rim elevatian? [� Yes ❑ No <br />Is the side sewer cu�entiy UNPR�T�CTED from sewer backvps (does not hav� a Bt11lD insfiafled)? �] Yes ❑ No <br />5ite lnspec�ion Ch�ckfisfi: <br />Alf ifems musf be checked `Yes' before rnspecfion is considered complete <br />Was side s�wer N inspected from building to sewer main? [� Yes ❑ Na Condifion: <br />Does side sewer have at least 1% slopa from the building ta sewer main? [� Yes ❑ No Describe: <br />Have all buifding sewer drain conneciions to the side sewer been identified and locafed? [f ] Yes ❑ No <br />Have aIl property storm drainage connections to the side sewer been idenfified and located? �] Yes ❑ No <br />Has prQperky been evaluated for drainage deficiencies wifh findings communica#ed to property ownet7 � Yes ❑ No <br />Instailation Defails: . -_===_=-' <br />What type and brand of BWQ was insfalled at this e(Clean Check BVW, Gr�nder ump, etc.), <br />Where was the device installed {general descnption, at�ach map "��"� �� <t( <br />, ., <br />Was there any ather sewer or storm drainage work coa�i@ied1in conjunction with the BWD work? 1s sa piease describe: ^.. <br />Installafion Checklist: . <br />Are al) downspouts and site drainage disconnected from ups#rearn o# the BV11D? �] Yes ❑ Na Comments: <br />Does BWD positioning meets minimum slope requirement af >1 %? j� Yes ❑ No C mments; <br />Can BWD be uifed aufi for ins ection and maintenance after loosening thumb screw? �Yes ❑ No <br />P __._ p�._ <br />Is SWD locked inta the pGope�r posifion and fhumb screw tighte `� Yes ❑ Na <br />Circle the BWD ver: imgation cover (lantlscape area} / tra#�c load be 'ng cover (drive surface} / access hatch (building) <br />Was praperty owner shown fhe locaf�on o"tl�staNed-� '� s❑ No Commen#s: <br />Praperfy Owner's SEgnafure: Da#e: <br />lnstalie�'s Signafure: Date; ,�^ � — - � <br />--�.� <br />Revision: Z 1 .�Friday, September 12, 2014 <br />