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" � <br /> BACKWATER PREVENTION DEVICE FINAL I <br /> �, INSTALLATION CHECKLIST ! <br /> � <br /> � <br /> � �i cai� �����U �r ��d� SCa�� L LG: � <br /> Installalion Company Name and Conlact Info�S� � '• � J=' ' -� • � r - ! � '�' ;� � <br /> Date Backwater Prevention device(BWD)was installed:�(j�L����Date ihis form was completed: �o � <br /> Installation Property Owner Name and Contact In(o: '' - � 'Y� �Y (� i <br /> Property Address: 1 �J� q �ao� � <br /> i <br /> Pre•Instalfation Inspection Checklist: ' <br /> All ifems musf be checked'Yes'in order for a BWD!0 6e considefed for installation { <br /> Is there a basement or level of the house lhat is at or near assumed sevaer main eievation7[�Yes ❑No � <br /> Are there fixtures in the house located below Ihe upstream sewer manhole rim elevation? [�Yes ❑ No � <br /> Is the side se���er currenlly UNPROTECTED from sewer 6ackups(tloes not have a BUJD installed)?`�]Yes ❑No <br /> Site Inspection Checklist: : <br /> �II i�ems must be checked'Yes'before inspection is considered complete � � <br /> Was side sewer TV inspected from building to sewer main? �es ❑ No Condition: ___�D ' <br /> Does side sewer have at least t%slope from the buildiny to sewer main? �Yes ❑ No Describe: � <br /> Have all building sewer drain conneclions to the side se�ver been identified a d located? `[�Yes ❑No ' <br /> liave all property storm drainaye conneclions lo the side sewer been identified and lo�aied7 [c�'es ❑ No 4 <br /> Has property been evaluated(or drainage deticiencies�vith findings communicaled ta propedy owner7 (�Yes ❑No � <br /> Installation Dr.tails: r , <br /> What type and brand of BWD was inslalied at Ihis site(Clean Check BWV, Grinder pump,etc.):_�'��� i <br /> WIICR?Wi15 Illl'.device inslalled (general descriplion,atlach m�p)"1 .�p.P Q��7,�`„�(����,/�"�_�j(,cL.(� ' <br /> - -- � <br /> lNas ihere any olher sewer or s�orrn drainage work completed in conjunclion with ihe DWD vaork? Is so please describe._ i <br /> ----------��Q-- — � <br /> -- -- — , <br /> Installation Checklist: ' <br /> Are all dovmspouts antl site drainage disconnected irom upstream ot lhe BWD? �Yes ❑No Comments � <br /> i <br /> Daes [iWD pnsitioning meels minimum slope requirement of>t%? ��Yes ❑ No Comments:._ ; <br /> � <br /> Can BWD he pulled oul for insper.lion and maintenance atter loosening Ihumb screw? �Yes ❑tJo � <br /> Is[3WD;ocked inlo t ro(�cr{Dsilin and�humb screw lighlened? [�Yes ❑ No 1 <br /> Cirde Ihe BWD co r.r. iirigafioi r ndscape area)I Iraffir,load bearing cover(drive surfar,e)I ac�ess hatr.h (builtling) � <br /> Was property ovmer sho�m Ihe location o(Ihe installed BWD? �Yes ❑ No Cornments _ __ � <br /> /_� � <br /> f�operty 0wncr's Signature:_ _ � , Dale:��11-5 , <br /> 1 i <br /> Inslaller'sSi�7nature�= �alP:�_��=lS _ <br /> / - - � <br /> Rr.viijnn:7 ] Priday,September l2, 201.4 i <br /> � <br />