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! <br /> I <br /> i <br /> BACFCWATER PREVENTION DEVICE FINAL i <br /> INSTALLATION CHECKLIST ; <br /> i <br /> Inslallalion Company Name and Conlacl Info: c�'S PLUh1�ING&SERVICE LLC 360•69f-5759 ` <br /> Date Backwater Preventlon device(BWD)was inslalled: O 6-�-IS"� Date lhis form was compleled: (�C —/S'/S� � <br /> Installation Property Owner Name and Contact Info: ����rEe,� 1�c�C'��.su' `f �W��p^ � <br /> PropertyAddress: 01— 06 u°✓� I <br /> Pre•Installation Inspectlon Checklist: � <br /> All items musl be checked'Yes'in order for a BWD lo be considered lor insfaAadon i <br /> Is there a basement or level ot 1he house lhat is al or near assumed se�ver main elevaUon7�f Yes ❑No i j <br /> Are there fixlures in lhe house localed below Ihe upstream sewer manhole rim elevation��]Yes ❑No , <br /> Is the side sevrer currentiy UNPROTEC7ED from sewer backups(does not have a 81ND installed)? (�J Yes ❑No � <br /> Site Inspeclion C.hecklisl: <br /> ; <br /> All ilems must 6e checked'Yes'6efora inspection is considered complete � <br /> Was side sewer TV inspected from building lo se�ver main7 [�Yes ❑No Condifion: � _ � <br /> Does side sewer have at least 1%siope(rom the building lo sewcr main7 [�]Yes ❑No Describe:� •' <br /> Have all building sewer drain conneclions to th e sido sewer been identified and located9 �Yos ❑No � <br /> Have all properly storm dralnage conne�lions lo ihe side sewer been identified and loeated7 [�Yes ❑No I <br /> Has property been evalualed for drainage de4ciencles with findings communicated lo properly owner? ❑Yes ❑No � <br /> Installation Details: I <br /> What type and 6rand of BWD was instaiied at this sile(Clean Check BWV,Grinder pump,etc.):��' ��Y �-�-� ( <br /> Where was the device inslalled(general d,scription,atlach^map)? �� l.rr��'+�a v. �n.r v�,�,w�- � <br /> l.N�t.�✓ v'-lc`l�ri`T`t_�_� Jv�owkl+�J � ,_ � .r- ,,J.1e1.�. - — i <br /> Was lhete any olher sewer or slorm drtdnage work completed In conjunction wilh Ihe BWD work7 is so please descnbe:_ I <br /> fv"O + <br /> Installation Checklist: � <br /> Are all downspouls and site dreinege disconnected 1rom upsiream of Ihe BWD7 f�f Yos ❑No Commenls: �u- ; <br /> Does BWD positioning meets minimum slope requiremenl of>t%? �Yes ❑No Comments: �''� <br /> Can BWD be pulled oul lor inspeetion and maintenance afler loosening thumb screw? [�Yes ❑No <br /> Is BWD iocked into lhe proper posilion and Ihumb screw tightennd7 �Yes ❑No <br /> Circle ihe�WD cover:inigation cover(landscape area)I tratfc load bearing cover(drive sudace)I access hetch(huilding) <br /> Was propedy owner sho�•m Ih ocation o(Ihe installed _";WD9 �Yes ❑No CommeMs: �i_tstr� <br /> Property Ovmcr's Signalur • o ,a,t,L Dale: ��] � <br /> Installet's SignaWre: w Dale: � "�� `1� <br /> Revision:2 1 Friday,Seplem6cr]l, 2014 <br />