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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: � k'Jl�l-�l 'l�-�� � �+Z� `"�o ��� ��� Z 3 <br /> Dale Backwaler Prevention device(BWD)was inslalled: 'lr.l —1 ate lhis torm was completed: IZ"��'� S� <br /> Instaliation Properiy Owner Name and Contact Into: 1�,l_�V �i� S A� �S��S�Z-���� <br /> PropertyAddress: �7 'Z-2-� �11�-�- c�Q-a-�'fi -�NL-� <br /> Pre•Installation Inspection Checklist: <br /> AI!ilems must be checked'Yes'in order lor a BbVD to be considered/or insfallation <br /> Is there a basement or level of the house that is at or near assumed sev�er rtiain elevation? [�'es ❑No <br /> Are there Gxtures in ihe house located below ihe upstream sewer manhole rim eievafion? [L�'�s ❑No <br /> is lhe side sewer currently UNPROTECTED from sewer backups(does not have a 8WD installed)?��fes ❑No <br /> Site Inspection Checklist: <br /> All ifems must be checked'Yes'belore inspecfion is considered complete <br /> Was side sevrer N inspected from building to sewer main? �a'es ❑ No Condition: �2 .� I\n-5 TG�� <br /> Does side sewer have at ieast 1°/a slope From the building to sewer main? [i�-YEs ❑ No Oescribe: <br /> Have ail building sevrer drain conneclions to the side se;rier been identified and localed? l[�-Y� ❑ No <br /> Have aii property stortn drainage connections to the side se�.ver been identified and located? �.Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property ovmer? �'.�s ❑No <br /> Installation Details: <br /> What type and brand of BWD was installed at this sil (Clean Check BWV,G nder pump,etcJ: <br /> Where was the device installed (general description, attac m�ar l �'�-- lI P,�.✓`G� - L� (j'Y��� <br /> `/�l�Lw � ��_��V�( Il'li/7il ' <br /> Was lhere any other sewer or slorm drainage work completed in conjunction wilh lhe ByvD work? Is so ease,descrihe:_ <br /> (' u-T ��k.r�. S� �--'"h / I�I C o�ci <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnecled from upslream of ihe BWD? ❑Yes [�.ido Comments: <br /> Does 8WD positioning meets minimum slope requiremenl uf>1%? ['l�`� ❑No Commenfs: � <br /> Can BWD be pulled out for inspection and mainlenance aiter loosening ihumb scre�v? �s ❑No ' <br /> Is BWD locked into tha proper position a w tighlened? [�fEs ❑ No <br /> Circle Ihe BWD cover: irrigation er(landscape are !lraHic load hearing cover(drive surface)I access hatch(buildingj <br /> Was prope�ty owner shown Ihe location of the installed BWD? es ❑ No Comments: <br /> Property O�vner's Signa Date: I Z��' �5 <br /> � � <br /> Installers Signature: Date: 1Z--��-�'� <br /> Revision: 2 1 Friday,September 12, 2014 <br />