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BACKWATER PREV�NTION DEVICE FINAL <br /> INSTALLATIOfd CHECKLIST <br /> Inslallafior Com an Name and Contact Info. t� �- _ — � Z � <br /> P Y i <br /> Dale Backwater Prevention device(BWD)was inslalled: r Dale this fortn was completed: '�a'7�/� ' <br /> Installation PropeAy OwnerName and Conlact Info: �-?�'� IC'.L�nA� Y�ilTc� (..�.e ��TY�- <br /> Property Address: �1 D��. �Q'.l�S <br /> Pre-InsWllaBon Inspection Checkiist: � <br /> Aii dems must 6e checked 'Yes'in order lor a 9WD to be cansidered(or installation <br /> Is there a 6asement ot level of the house that is at or near assumed sewer main elevation?�s ❑No <br /> Are Ihere fixtures in the house located below the upstream sewer manhole rim elevationl[�.Y�s [�ido <br /> Is the side sewer currenHy UNPROTECTED irom sewer backups(dces not have a BWD installed)?�� 0 No <br /> Site Inspecdon Checklist: <br /> All dems must 6e checked'Yes'belore inspecfion is considered compfete <br /> Was side sewer N inspected from building to sewer main? es ❑ No Candifion: L � _D��-. <br /> Does side sewer have at least 196 slope hom Ihe building to sewer main� [(]Ve� ❑No Describe: <br /> Have all building sewer drain cannecfions to the side sewer been identfied and located? (t�Y�- ❑No <br /> Have all property stortn drainage connecfions to the side sewer been idenlified and located? �1'es ❑No <br /> Has property been evaluated far drainage deficien�ies with findings communicated to property owne� ([�.Ves ❑No <br /> Inatallation Details: (J <br /> What type and brand ot BWD was installed at this site(Clean Check BWV,Grinder pump,etc.):���-<-�� <br /> Where was the device inslalled(generai description altach map)7 ti'b9�f • <br /> ����� �1'T lS (�rktZec�7' ' <br /> Was ihere any other sewer or stortn dreinage work co p eted in conJunction wilh the�WD work? Is so please describe:_ <br /> ���„� _ <br /> insfallation Checklist: <br /> Are all downspouts and site drainage disconnected from upslream oi Ihe BWD? es ❑No Comments: <br /> Does BWD posifianing meets minimum slope requirement of>1%7 [�.1'es ❑No Comments: • <br /> Can BWD be pulled oul(or inspeclion and maintenance after loosening thumb screvll �-Yes ❑No <br /> Is BWD locked into the proper posifion and thumb screw tightened7 No j <br /> Circle the BWD cover:irrigation cover(landscape area traffic load bearing cover(dnye sudace)/access hatch(building) ; <br /> Was property owner shown the location oF ihe inslalled BWD? [J�f�s ❑No Commenls: <br /> Property Owner's Signatu • � �\� Date: �v�-I. l � I 5 I <br /> � <br /> Insfaller'sSignature: � Date: _'Z`�—( � � <br /> Revision:2 1 Friday,Septembe�12,2014 <br />