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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHEC!<LIST <br />Inslal!a!ion Comoany Name and Contact Ini�� <br />�� <br />Date Backe�ater Prevenl�on device (BWD) was installed�fL?.�� ��S _ Dafe <br />Installation Property Owner �;ame and <br />Prop�rty Address: <br />Pre•Installation Inspection Checklist: <br />RII ifem,s must be checked 'Yes' m oroe� lor a 8WD lo be cons;oered (or insfallalion <br />��,�-`�i,--�._�/' <br />s form v,�as completed: ���Z7� 7� <br />i� <br />Is there a basemenf or level o` tne nocse tha; is at or near as;umed sewer main elevation?,� Yes ❑ No <br />Are fnere fixtures in the house Iccaled belo�v �e ups;ream sev:�er manhole rim elev2tion? 1�'Yes ❑ �o <br />Is the side sev�er currently UtJPROTECTED from sewer backups (does not have a 8!ND installed)?�1'es ❑ IJo <br />Site Inspection Cliecklisl: <br />Af! ifems must be checked'Yzs' be(ore inspecfion is considered camplet� <br />"/as side se�•�er N inspecled from building lo sewer main? ,}� Yes ❑ No Condition: <br />Dces side seat�er have at least t% slope from Ihe building to se.ver main? �Yes ❑ No Descnbe: <br />Nave all t�uilding se:rer drain c;onnecUons to Ihe side se��rer beer�. identi'ied and located? � 1'es ❑ Nc <br />Have all property storm d�ainage connections lo the side sewer been identi!ied and located? '�%� Ycs ❑ No <br />Nas property been evaluated foi drainage deficienc�es �•�ith findings communicaled to properiy ovmer'? � Yes ❑ No <br />Instaliation Details: <br />VJhat lype and brand of BWD was insialled at fhis sile (Clear. Check 8'PN, G inder pump, etc.): <br />4Vhere was Ihe device insfalled (general descrip!,on, aftach map)� � j 1� � <br />'eVas ihere ar,y qlh�r se,cer or Storrn drainage �,rork compleled in conjur�clion �vith tne BWD v;ork? Is so please descrine: _ <br />t� 1 f J� <br />-+ v-t ��, <br />Installation Checklish <br />Are all downspuuts and site dranage diswnnecled froin upstream of Ihe BW�'� I� Ycs <br />Does BWD positioniny meels minimum sfope requirement of >1%? � Yes ❑ No <br />[_] No Commenls: _ <br />Comments <br />�an BV��D he pulted out for inspeetion and maintenance afler loosenmg Ihumb screv✓? ,�] Yes ❑ No <br />Is BWD Iocked into Ihe proper posilion and thumb screv� tightened? � Yes ❑ No <br />Circie the B�ND cover. irrigation cover (landscape aiea)1(ra(f c load beanng ccver (drive suriace) ! access halcn @uilding) <br />Was property owner shov:n �he tocat�on oi the inslalled BWD��Yes ❑ No Commenfs <br />Property O�vner's <br />Installer's Signalure: <br />Rrvsion: 2 <br />Dale: �17 — ZZ `�� <br />Dale: �g �- �`�r � <br />Piday, Septe��bcr 12, ?014 <br />