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gACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Inslallalion Company Name and Contacl Info: /41�I--�I�< < < ��� ���`— 6/Z� <br /> Dale Backwaler Prevention device(BWD)v�as insta�led:l�_R t 5 Date this torm was completed: — �S <br /> Installation Property Ov+ner Name and Contact Info`�'v�b r 1 R—f"�1•�✓� <br /> Property Address: r Z� L�� <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order(or a BWD to be considered forinstallation <br /> Is there a basemenl or level of Ihe house lhat is al or near assumed sewer main elevalion?� ❑ No <br /> Are there tixlures in the house located belo�v the upslream sewer manhole rim elevalion? es ❑ No <br /> Is the side se�ver currenlly UNPROTECTED from sev+er backups(does not have a BWD inslalled�?�`gs ❑ No <br /> Site Inspection Checklist: <br /> All items must 6e checked'Yes'before inspection is considered complete A/ w , 1 <br /> Was side sewer TV inspecled from building to sewer main? [�.1`e's ❑ No Contlition: ��•r�"� <br /> Does side sewer have at leasl 1%slope from the building to sewer main? � ❑No Describe: <br /> Have all building sewer drain conneclions to the side sewer been identified and located7 (�-Yes ❑No <br /> Have all property storm drainage connecGons to the side sewer been identified and located? [�-Yes ❑No <br /> Has property been evaluated tor drainage deficiencies tivilh findings communicated to prope�ty owner? [[�-Ves ❑No <br /> Installation Details: , �� <br /> What type and brand of BWD was installed at this site (Clean Check BWV,Grinder pump, etc.): � <br /> Where�vas lhe device instalied(general description,atlaeh map)? d � � �^^:� <br /> Was there any olher sewer or slorm drainage�vork co pleled in conjuncti n wilh Ihe BWD�vor{;7 Is so please de cnbe:_ <br /> � � �1ti� ��0�-� C�P� ' <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnected irom upslream oi Ihe BWD? []�'�s ❑No Comments. <br /> Does BWD posilioning meets minimum slope requirement of>1%? [}�`¢s ❑No Comments� <br /> Can BWD be pulied out for inspeclion and maintenance afler loosening thumb screw? [}Ye�s ❑No <br /> Is BWD ocked into lhe proper position and t w tightened? es ❑No <br /> Circle the BWD cover: irrigation cover dsca e area I ific load bearing cover(drive surface)1 access hatch(building) <br /> Was prc.�erty owner shown the localion of the inslalled BWD? []Y� ❑No Commenls: <br /> Property O�vner's Signalure: /� ��A—�— <br /> Dale: Zv"� <br /> Installer's Signalure: V�`^'v Dale:1��� S <br /> Revision: 2 1 Friday,September 12, 2014 <br />