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� <br /> ; <br /> I <br /> BACKWATER PREVENTION DEVICE FINAL i <br /> INSTALLATION CHECKLIST : <br /> i <br /> � <br /> Installation Company Name and Contact Info: �� �► � 2r�/��l'C'� z�� ; <br /> Date Backwater Prevention device(BWD)w:�s inslalled: -�Z ��"�� ale this form was compleled: -Z v—� , <br /> Installation Properly Owner Name and Contact Info: C.n7,�.F v�fd[11� ��1 7� �� � 3 �f i <br /> PropertyAddress: I�� �7 (K�/�--� r`�G�` '"�l/-�y�.P�j � <br /> Pre-Inst�llation Inspection Checklist: <br /> All ifems must be checked 'Yes'in order for a BWD to be considered lor installation <br /> Is there a basement or level oF the house lhat is at or near assumed sewer main etevalion? +[�fes ❑No ; <br /> Are there fixtures in the house located be!ov�the upstream sewer manhole rim elevation?�'�s ❑No ; <br /> Is Ihe side sewer currently UNPROTEC fED from sewer backups(does not have a BWD installed)7 [(�,1Fes ❑No ; <br /> � <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'be%re inspection is considered complete ; <br /> Was side sewer TV inspected from building!o sewer main? [}�s ❑ No Condition:C� G7J�'' ! <br /> Does side sewer have at least 1% slope frorr�the building to sewer main7 [�X�s ❑No Describ : j <br /> Have all building sewer drain connecfions to the side sewer been identified and located7 {[�es ❑No , <br /> Have all property storm drainage cc�nec6ons to the side se�ver been idenlified and located? [�]�Les ❑ No : <br /> Has property been evaluated for drainage deficie�cies with 6ndings communicated to property ownef? [�]Yes ❑No � <br /> Installation Details: / � <br /> What type and brand of BWD was installed at this sile(Clean Check BWV,Grinder pump,etc.):,��i��G'L-e-«t- � <br /> Where was lhe tlevice installed (general description,attach map)? �r9c��L L_iGssr� �-Qe ���� . j <br /> I <br /> i <br /> Was there any other sewer or slorm drainage work com eted in conjunction wilh the BWD workl Is so please describe:_ : <br /> F" D fM-z" , <br /> Installation Checklist: � <br /> Are all do�vnspouts and site drainage disconnected irom ups;ream of the BWD7 �� No Comments: �D1't-C � � <br /> Does BWD posilioning meets minimum slope requirement of>1%? t[�Y� ❑ No Commenls: � <br /> Can BWD be pulled out tor inspection and maintenance a�!zr loosening thumb screw7 �]1'.as ❑No i <br /> Is BWD locked into the proper position and lhumb screw tightened? [�.1'es ❑No � <br /> Ci�cle the BWD cover:irrigalion cov (landscape area)f raffic load bearing cover(drive surfa�e)!access hatch (building) � <br /> Was property owner shown ihe location of the installed BWD? [�-Ye� ❑ No Comments: j <br /> ; <br /> Property Owner's Signalure• ,. Dale: ��—Z �✓Sf ! <br /> Instatler's Signalure: � Date: �Zo-�� � <br /> t <br /> Revision: 2 1 friday,September 12, 2014 ' <br /> 1 <br />