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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLA710N CHECKLIST <br /> Ins;allation Company Name and Conlact Info: '�"��1`U J'� nn�'1f�S <br /> Date Back�vater Prevention device(BWD)was insfalled: �'� - ��S Date this form was completed:s " Z��� <br />� Installation Property Ov�ner Name and Confact Info: V U�� C���-�-( � <br /> Property Address, �3 a-`� Cn�h�e <br /> Pre-Installation Inspeclion Checklist: <br /> Afl ilems must be checked'Yes'in order for a BWD to 6e considered for installation <br /> � Is there a basement or level of the house that is at or near assumed sev;er main elevation7�Yes ❑No <br /> Are there fatures in the house located beloa+the upstream sewer manhole rim elevation? Yes ❑ No <br /> Is the side sevaer wrrently U�PROTECTED irom sev.�er backups(does nct have a BWD installed)7 QI Yes ❑No <br /> Site Inspection Checklist: <br /> A!1 ifems must 6e checked`Ves'before inspection is considered complele <br /> I�Jas side sewer N inspected from building to se�ver main? {]Yes ❑No Condition, <br /> Does side sewer have ai leasl 1%slope(ro�„�he building to se�ver m�in? �Yes ❑No Describe; <br /> Have afl building sewer drain connections to the side sewer been identifed and I�caled? [�Yes ❑No <br /> Have ail properiy storm dr2inage connections to lhe side sewer been idenGfied and located7 [�Yes ❑ No <br /> Has properiy been evaluated for drainage deficiencies wifh findings communicated to property o�vner7 �]Yes ❑ No <br /> Installation Details: <br />' VJhat type and brand of BWD v�as inslalled al this site lean Check BV Grinder pump,etc.): <br /> '"��here e+as ihe device instailed(general description,attach map)? �� � < <c�-nQ �a� ��F C{� <br /> ,l�vs-l-- <br /> V1�as lhere any other sewer or slorm drainage vrork c�pl�t�n conjunction with the BWD work?Is so please describe:_ <br /> �1 <br /> Installation Checklist: <br /> fve all downspouls and site drainage disconnes�ed irom upstream of the BWD? [�Yes ❑No Commenis: <br /> Does BWD positioning meets minimum slope requirement of>1%? �]Yes ❑No Comments: <br /> Can BVl'D be pulled out tor inspec0on and mainlenance after loosening lhumb scre�v7 �Yes ❑ No <br /> Is BWD locked into the proper p�ion�nd-th b screw fightenedT �Yes ❑No <br /> Circle the BWD cover. i�ion cover(landscape area) ffic load bearing cover(drive surtace)1 access hatch(building) <br /> Was property owner shown the ocabon o e nsta led BVJD9 (ZJ Yes ❑No Comments: <br /> Property Owner s Signature: Date: <br /> installers Signature: Date: ��� � �Z � �� <br /> Revislon: 2 1 Friday,September 12,2014 <br />