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_ BACKWATER PRETION CHECKL.IST �INr.L <br />� <br />INSTALLA <br />i i G ^Y :J iOC ;7G�"-� �'— '� <br />�Y�rt Cczn �(� ' . � <br />` c " .c i�`,r;:.,,�..��Sci,J(j• �,a <a�u)-,r.�,...�n.S:� <br />Installation Company N�me and Conlact Into ��' �� �' ��"� <br />was installed:�J--- Date this form aas compleled �-�-- <br />Date Back�vater Prevenlion device (BWD) � � 1' ^ �M1, �� �Lo,���� � ` (o7b <br />Installation Property Owner Name and Contact <br />Properiy Address: <br />Pre-Installation Inspeclion Checklist: <br />All items must 6e checked 'Yes' in order for a BW� to be considered for installafron <br />� �Yes ❑ No <br />Is there a basement or level of Ihe house ihat is at or near assumed sewer main elevation. <br />Are there fxlu,es in ��� nf ��UNPROTECTED from seeveabackups (does notrV ave a BWD in�� e�1� ��S ❑ No <br />Is the side setirer curre y <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete _ <br />Was side sewer TV inspecled from building to sewer main? � Yes ❑ No CeSdifi❑on�o Des� _-- <br />Does side sev�er have at least 1% slo{.e irom the building to sewer main. � � No <br />Have all building sev�er drain r,onnections io the side sewer been identified and localed? ' eSY� ❑ No <br />Have all property storm drainage conneclions lo thc side sewer been idenlified and located �� <br />Has property been evalualed tor drainage deficiencies with findings communicaled to property o�vner? � Yes ❑ No <br />Installation Details: ' � r ' " <br />What type and brand of BWD was inslalled at ihis site (Clean Check BNN, Grinder pump, etc.�d����,� <br />Where was the device installed (general description, allac�i map)? �L:� <br />VJas lhere any other sewer or slorm drainaye work completed in conjunetion with lhe BWD work? Is so please describe: _ <br />---- ----- -t-`U�'l�__ _ <br />Instaliation Checklist: No Commenis: ________- <br />Are all dovanspouts and site drainage disconnected irom upstream of the RWD? ���SC m��Ns: _____ —_ ----- <br />Ooes BWD posilioning meets minimum slope requiremenl oi>1%? �,�'es �_� <br />Can BWO be pulletl oul for inspeclion and maintenance afler looseniny thumb screv�? � Yes ❑ No <br />Is BWD locked inlo the proper posilion a�d ihumb screw tightened? �Nes ❑ No <br />Girde ihe BWD �ove �: rriyalion� e� dscape area)1lraftic load bearing cover (drive surtace)1 a�r.ess hatch @uildmg) <br />Was property owner sh-o � he (ocalion of the inslalled BWD? �(] Yes ❑ No Commenls � <br />��-� Date: / � �J �- S -�- <br />rroperty Owner's Signature: � Date. 7� � l-�S <br />Installer's Signatur�__��t�-v-�-�-- <br />/ � Friday, SePtember 17_, 2014 <br />Revision: 2 <br />