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� <br />� <br />BACKWATER PREVENTION DEVIGE FINAL <br />INSTALLATION CHECKLIST <br />Instatlation Company Name and Conlact Into� r� <br />Dale Backwater Prevention device (BWD) was insla <br />Inslallation Properiy Owner Name and Contacl Info: <br />Property Address: L(.�( 1 � /CI-���n� <br />Pre•Installation Inspeclion Checklist: <br />Date this torm �vas completed <br />All items must be checked 'Yes' in order lor a BWD to be considered (or installation <br />Is there a basement or level of ihz house that is at or near assumed see;er main elevation? �j Yes �-1 �o <br />Are there fixtures in the house locatetl helo:v the upsUeam se+:�er manhole rim elevation?�Yes ❑ No <br />Is !he side sewer currently UNPROTECTED from se•aer backups (does not have a BWD instalted)�Yes ❑ No <br />Site Inspection Checklisl: <br />AR items mast be checked'Yes' be(ore inspection is considered complete <br />4Vas side sew.er TV �nspected from building to sewer main? � Yes ❑ No Condilion: <br />Does side se�ver have al leasf 1°/o slope irom lhe building to sevrer main? �Yes ❑ No Describe: <br />Have all building se�ver drain connections to the side sewer been idenlified anc located? �Yes ❑ No <br />Have all property storm drainage conn�ctions to the side se�,ver been itlentiFed and localed? �Yes ❑ No <br />Has properly been evalualed for drainage deficiencies with findings communicated to property o�vner? �Yes ❑ No <br />/� <br />Installation Details: <br />1Nhat rype and brand of BWD �vas installed at this site (Clean Check BWV, Grinder pump, etc.): � �' <br />i <br />1Nhere v:as the devi�e insialled (general description, atlach map)? ti% �i�jSP . <br />INas there any other sewer or storm drainage �,�ork completed in conjunclion wi}h ihe B�UD �vo/rk�? Is s�o please describe:-y�� <br />n �.. . .-. . „ - -' n /I .� _ .. n � Jn �. .. � . �/ /��n A. / / '�ne f' /j$ C (lJ.:lfJ C.N! [;� <br />Are all do�vnspouts and site drainage disconnected irom upstream of the BWD? �Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement o(>1%7 j Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loose ing ihumb screw? � Yes ❑ No <br />Is BWD locketl into the proper position and thumb screw lightened? (� Yes ❑ No <br />i <br />Circle lhe BWD cover. irrigation cover (landscape area) I irafiic load bearing cover (drive sur(ace) f access hatch (building) <br />Was property o�vner shown the location of the <br />Property Owner's Signature: <br />/ <br />Installer's Signalure: � <br />Revision: 2 <br />BVUD? ❑ Yes ❑ No <br />� <br />Commenls: _ <br />Date� % �� � �— <br />Date: <br />Friday, Sep:ember 12, 2014 <br />