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i <br /> { <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> INSTALLATION CHECK�IST � <br /> � <br /> Inslallation Company Name and Contact Into: ,� f i�„�,.�� L j�C,. � <br /> Daie Backwater Prevention device(BWD)�vas inslalled:��l �5 ,Date this (orm was completed: L�}- $ { <br /> Installalion Property Owner Name and Coniact Info:_ �`JIk�1 +�J Ii,(� ,p,ys�.t��-��1� i <br /> Property Address:��� GOL�`f /{'�/� / .��,/��(� y� l��� I ; <br /> t <br /> Pre-Installation Inspection Checklist: j <br /> All ifems must be dtecked'Yes'in order for a BWD to be considered la rnstallation � <br /> Is Ihere a basement or level o(lhe house lhat is at or near assumed sewer main eievation? j <br /> � Yes ❑No <br /> Are there fixtures in the house located below Ihe upstream setver manhole rim e�evalion?,� Yes ❑ No � <br /> is�he side sewer currenGy UIJPROTECTED from sewer hackups(does not have a BWD insialled)? �Yes ❑No ! <br /> Site Inspection Checklist: ! <br /> i <br /> Afl ifems must be checked'Yes'before inspection is considered complete � <br /> Was side sewer N inspected from building to sewer main? (�Yes ❑ No Condition: ` <br /> Does side sewer have at least 1%slope (rom the building to sewer main? [�..Yes (]No Describe: � <br /> Have all buildiny sewer drain wnnec(ions to lhe side sewer been identified and located? �Yes ❑No E <br /> Nave all property storm drainage connections to Ihe side sewer been identified and lo�ated? [�,Yes ❑No � <br /> Has property been eva��ated for drainage deflciencies with findings communicated to properiy owner9 �Yes ❑ No � <br /> Installation Details: ' <br /> t <br /> What type and brand ot BWD was inslalled at this site(Clean Check BINV,Grinder pump, etc.): C l�av� e�2��L # <br /> N�here was the device instalied(general descriplion, attach map)? @��,�!-�;i CQ.a �c�il S e. t <br /> Was Ihere any other sewer or slorm drainage work compieted in conjuncfion with ihe BWD work?Is so please descnbe: ! <br /> N O — <br /> i <br /> Installation Checklist: I <br /> Are all drnvnspoul,and sile drainage disconnecled(rom upstream ol the BV1�'D? H Yes [J No Commenls: � <br /> t <br /> Does BWD positioning meets minimum slope requiremenl of>t%? �Yes ❑ No Commenls� <br /> Can BWD be pulled out for inspeclion and mainlenance after loosening thumb screw? �Yes ❑No � <br /> i <br /> Is OWD locked into the proper position a lhumb screw lightened? .�Yes ❑ No ; <br /> a <br /> Circle lhe 8WD cover: irrigation crov r(lantlscape e !traffic load bearing cover(drive surface)!access halch(building) i <br /> Was properly owner shown�he localion o(ihe installed BWD1 [�Yes ❑No Commenis: <br /> i <br /> Property Owner's Sig�alure: ! <br /> Date:��' �S <br /> Installer's Signalure: _ � -�A Oate: 2���7/�� ' <br /> Revision: 2 1 Friday, September 12, 2014 I <br /> \ I <br />