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�AGKWATE� PREd/ENTfON DEV�CE FlIVAL <br /> � lN�T'ALL.AT��N �HIE�KLIST <br /> �ri���f� ��� ��= � ��t+� ��:p:�"`` � �.� <br /> ,, � <br /> Instaflation Company Name and Contact Info������ - ,L�; --� �� ,.` � � `�� ,�. ;� 3 <br /> Qate Backwater Prevention device(BWD)was installed:^ Date this form was completed: <br /> _ <br /> _ ��, <br /> lnsfallafEon Property Owner Name and Contact info:���CG� �Q P�_�n � �c���r�D��C��,�. i <br /> Proper�yAddress: ��ba �:b '�"` �c`j`�-�__r_�-(��'lt.�Q� � g�-�?_� <br /> Pre-Instaliafiion Inspection Checklist: ' <br /> All ifems musf be checked`Yes'in order for a BWD to be considered for installafion � <br /> Is fhere a basement or level of the house that is at or near assumed sewer main elevation? �es ❑ No <br /> Are fhere fixfures in the house lacated beiow the upstream sewer manhole rim elevation?[�°1'es ❑ No lal, <br /> Is fhe side sewer currently UNPROTECTED from sewer backups (tloes not have a BWD installed}? [�Nes ❑ No � <br /> Site fnspection Checklist: - <br /> A!!items must be checked`Yes'befare inspectron is�onsidered complete <br /> Was sitle sewer TV inspected from buifding to sewer main? [�'es [� �lo Condition: �"�CR� <br /> Does side sewer have at least 1%slope from the building to sewer main? [�'Yes ❑ No Describa: ?5 <br /> Have all building sewer tlrain cannections to the side sewer been itlentifietl and located? [�Yes ❑ No ', <br /> Have all property starm drainage connections to the side sewer been identified and located? �es ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to properky owner? �Yes ❑ No <br /> installation Details: f' <br /> What type and brand of BWD was instaHed at this site (Clean Check BWV, Grintler pump, etc.): �` <br /> Wf�ere was the device installed �general description, atEach map)? ��_ ,�'^a(�1P������� <br /> Was there any other sewer or storm drainage work completed in conjunction wi#h the BVIlD work? Is so please describe:_ ; <br /> �y� <br /> Instalfation Checklist: � <br /> Are all downspauts and site drainage disconnected from upstream of the SWD?�'4'es ❑ No Comments: - <br /> Does BWD pasitioning mee#s minimum slope requirement of�1%? [�i'es ❑ No Comments: <br /> Can BWD be pulled ouf for inspection and maintenance ai#er laosening thumb screw? �Yes ❑ No <br /> is BWD locked into the roper position and thumb screw fiightened? �Yes ❑ Na <br /> Circle the BWD co r_ irrigation cover l�ndscape area} 1�raffic load bearing cover(drive surface)I access hatch(building} <br /> _ _ _ _ _ _.. <br /> _. _ __. _ . _ ,.. <br /> _,.. <br /> Was property owner shown e ocation of the installetl BWD? ,�'es ❑ No Comments: <br /> ;; <br /> Property Owner's Signafure: Date: o <br /> � <br /> Installer's Signatu : � Date: ��_� � <br /> Revisidn; 2 1 �riday,September 12, 2014 <br />