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BACKWATER PREVENTION DEVICE+j� �N�1��� �, D <br />�, INSTALLATION CHECKLIST � Q�q o 1 10�5 D <br />Inslallalion Company Name and Contact Info: <br />:t:���t. ..tCS <br />L <br />Date 8ackwater Prevenlion device (BWD) was installed: Date lhis (orm was completed: <br />Installalion Proper!y O�vner Name and Contacl Info: <br />Property Adtlress: ��� <br />� <br />Pre-Installation Inspection Checklist; <br />All ilems mus( be checked '1'es' in order (or a B WD fo be considered for inslallalion <br />Is Ihere a basement or level oi ihe house thai is al or near assumed sewer main elevalion? [�.Yes ❑ No <br />Are there tixlures in the house localed below the upsiream seiver manhole rim elevation? �Yes ❑ No <br />Is ihe side se�ver curren0y UNPROTECTED (rom sewer backups (does nol have a BWD installed�? �C,Yes ❑ No <br />Site Inspection Checklist: <br />All items musl be checked 'Ves' be/ore inspeclion is considered wmplefe + <br />Was side se�ver TV inspected from building to sewer main? �.Yes ❑ No Condilion: ��+k�� �v l C�oD� �1�' <br />Does side sewer have at leasf 1% slope (rom Ihe building to sewer main? � Yes ❑ No Describe: <br />Have all building sewer drain connection� to lhe side sewer been identilied and localed? [� Yes ❑ IJo <br />Have all property storm drainage eonnec�ions lo the side sev�er been idenlilietl and locate�? 0 Yes ❑ No <br />Has properly been evaluated (or drainage deficiencies wilh lindings communicaled to property owner? [j� Yes ❑ No <br />Installation Details: <br />lNhal type and brand of BWD was installed al this site (Clean Check BWV, Grinder pump, efc ): Cl'�w e.�`:���u1 V <br />VJhere was Ihe device installed (general description, allach map)? i� Rr�� �r,w..+?,- 1c� O� �c�o <br />Vdas there any other sewer or slorm drainage �vork compleled in conjurclion with Ihe �WD crork? Is so please describe: <br />�.=0 <br />Ins.tallation Checklist: <br />l�re all dov+nspouls and sile drainage disconne�ted irom upslream o( ihe BWD? � Ycs ❑ No Comments: <br />Does BWD positioning meels minimum slope requiremenl ol >1%9 [�Yes j] No Commenls: <br />Can BWD he pulled out for insper,tion and mainlenance afler loosening Ihumb screw� ❑ Yes �_� No <br />is BWD locked into the proper posifiun and thumh screw lightened� �Yes ❑ No <br />Cirde the BWU cover. irrigation cuver (landscape area) I lra(tic load beanng r.over (drive suriar,e)1 access halch (building) <br />Was properly owner shown Ihe <br />Properly Ov✓ner's 5 ia � <br />�� <br />inslaller's Signalur <br />Hevision: ) <br />i�Yes <br />❑ No <br />Comments: <br />Date: S — I I —1 � <br />Date: �--Zb'iS� <br />I'riday, September 12, 2014 <br />