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BACKWATER PREVENTION DEVICE FINAL <br />E„ INSTALLATION CHECKLIST <br />�ri c�zn �;p ; �� F.� �de se.��, � �c <br />Installation Company Name and ContaG Info:,�L' C',C��1�},,�;):�+-��5�� �'.�i ��i G?i?i„);��IO. �?lJ` <br />Date Backivater Prevention device (DWD) was <br />Installation Property Ovmer Name and Contact In(o: <br />Properiy Address: <br />Date this form �vas <br />Pre-Installation Inspection Checklist: � <br />All items must be checked 'Ves' in order (or a 8WD b be consideied for installation <br />Is ihere a basement or level of the house ihat is at or near assumed sewer main elevation�es ❑ No <br />Are there fixtures in ihe house located helotiv the upstream se�ver manhole rim elevation? es ❑ No <br />Is the side sewer currenlly UNPROTECTED irom sev�er backups (does not have a BWD inslalled)? [�es ❑ No <br />Site Inspection Checklist: <br />All items musi be checked 'Ves' before inspection is considered complete <br />l4�as side sewer TV inspected from buildingdo sewer ma;n? (�Yes ❑ No Condition: �(�� <br />Does side sewer have al least 1% slope irom ihe building to sewer main? � Yes ❑ No Describe: <br />Have all huilding sewer drain connections to ihe side sewer been identified and lo�ated? (� Yes ❑ No <br />Have ali property storm drainage connections to ihe side sewer been identified and located? �Yes ❑ No <br />Has property been evaluated for tlrainage deficiencies with f ndings communicated to property owner? �}'Yes ❑ No <br />Instailation Details: i� ���., <br />What type and brantl of BWD was inslalled al lhis sile (Clean Check BWV, Grinder pump, etc.): ,��,rr •7a' ' <br />l�'here �vas lhe device insialled (general description, attach map)? 7�Q ��%l'�10���,�_ <br />14�as there any othe sewer or stor draina,9 e��ork compleled in conjuncfion �vith fhe BWD e��ork? Is so please describe: _ <br />��',����/�-�' , �� S�n �,�t �ym'Vl -�lrS � ' , � <br />installation Cheeklist l�''� < < �`-� <br />Are all downspouts and site drainage disr.onnccted from upsUeam of the BWD? �Yes ❑ No Comments: _ <br />Does BWD positioning meets minimum slope requirement oi >190? �l'es ❑ No Comments: <br />Can BWD 6e pulled out for inspeclion antl maintenance after loosening ihumb scre�v? �Yes ❑ No <br />Is BWD locked into the prope osition and ihumb screev lightened? �Yes ❑ No <br />Circle the BWD cover. ' rigation cove hdscape area) / traflic load bearing cover (drive surface)1 access hatch (builtling) <br />Was property owner shown Ihe location�f Ihe ��stalled 814�D? �'Yes ❑ No Commenis: <br />Property Owners Signalure: <br />Inslaller's Signaiure: <br />Date: � �` <br />Dafe: � <br />_ <br />Revision: 2 � V 1 Priday, September 12, 2014 <br />