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i <br /> . I <br /> � <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> lnstallation Company Name and Contact Info: ���o�� �It.�w�4f��nG I <br /> Date Backwater Prevention device(B4VD)was installed: 5��-�7 -1%Dafe thfs form was completed:. �- J-`�-r 5- i <br /> installation Property Owner Name and Contacl Info: �.c�h.P �1- ��� L✓ ' <br /> PrapertyAddress: � �L11'1 (� �v�-C S'� I <br /> Pre-Installatlon Inspection Checklist: i <br /> All items musf be checked'Yes'!n order for a BWD fo be considered for fnstalfatlon � <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation7(�]Yes ❑ No � <br /> Are there fixtures in the house located 6eloa the upstream sewer manhole rim ele�ation?�]Yes ❑No <br /> Is the side sewer currenlly UNPROTECTED irom sewer backups(does not have a BWD installed)?�Yes ❑No I <br /> Site Inspection Checklist: � <br /> � <br /> AI!ifems must be checked'Yes'before inspection is considered complete ; <br /> Was side sewer 1'V inspected from building to sewer main? �Yes ❑ No CondiNon: ; <br /> Does side sewer have at least 1%slope from ihe buiiding to sewer main? �]Yes ❑No Describe: <br /> Have ail building sewer drain connections lo the side sewer been ideni�ed and located? Qj Yes ❑ No i <br /> Have all property storm drainage connections to the side se�ver been identified and located7 [�Yes ❑ No ; <br /> Has properfy been evaluated for drainage deficiencies vrith findings communicated to property owner? �]Yes ❑ No i <br /> Installation Details: I <br /> What type and brand of BWD was installed at this site Clean Check BNN, inder pump,etc.): _ ;. <br /> �--_ <br /> Where was the tlevice inslalled(generai description,altach map)? �� � k i�.G�rol �� rl�.�Vf c�u�� ., i <br /> i/�.P r � c �n rc a.rL c�b n/ � <br /> Was lhere any olher sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe:_ � <br /> N� , <br /> , <br /> Installation Checklist: � <br /> Are all downspoufs and site drainage disconnected trom upsiream of lh BWD? �Yes ❑ No Comments: <br /> { <br /> Does BWD positioning meets minimum slope requirementof>1%7 �Yes ❑ No Commenis: � <br /> Can 8WD be pulled out tor fnspection and maintenance after loosening thumb screw7 (�Yes ❑No <br /> Is BWD locked into the proper position and thumb screw t'�hiened7_�Yes No � <br /> Cirde the BWD eover:imgatlon cover(landscape area) traific load bearing cover(drive,udace)1 access hatch(building) i <br /> Was property owner shown the location of the inslalled BWD? �Yes ❑ No Commen�s: � <br /> Properly Owner's Signature� Date: , <br /> Installers Signature: __—�—� "' Dale: �c��- �S <br /> Revision: 2 '—"` 1 Friday,September 12,2014 <br />