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� <br />� <br />BACKWATEF: PREVENTION DEVICE FINAL <br />INSTAL� ATION CHECKLIST <br />Instailation Company Name and Contact Info:,,1���' <br />Da1e Backwater Prevenlion device (BWD) v;as installe <br />Installation Property O�vner Name and Con;act in(o: � <br />G <br />Date Ihis form �vas compleled: <br />Property Address: �( h(� v l u.�.(� '7»-- � ►---v�Li-cc <br />Pre•Installation Inspection Checklist: <br />Afl items must be checked 'Yes' in order fcr •: ;WD to be considered (or installafion <br />..W/V � <br />is ihere a basement or level of �he house t�at is at or near assumed sewer main elevation? �l'es ❑ No <br />Are there fixtures in the ho�.�se located below Ihe upstream sewer manhole rim elevation? �'es ❑ No <br />Is the side sewer currenfly UNPROTFCTFD from sewer bacicups (does not have a BWD inslalled)? �tes ❑ No <br />Site Inspection Checklist: <br />Alf items musf be checked 'Yes' before inspection is considered compfete <br />Was side sewer TV inspected from buildin3 to sewer main? �r�Yes ❑ No Condilion: _�IC� <br />Does side sewer have at least 1;o slope from the builtling to se�ver main? �Yes ❑ No Descri�e: <br />Have all building sewer drain connections lo ihe sitle sev�er been idenlified and located? �'Yes ❑ No <br />Have all property slorm drainaye conneclions to the side sewer been itlentilied and located? j�'Yes ❑ No <br />Has property been evaluated for drainage defir.iencies wilh findings communicatetl to propedy owner? �Yes ❑ No <br />InstallationDetails: '��i„�, /,_ C � <br />Wha; type and brantl ot BWD �vas inslalled at this sile (Clean Check BWV, Grinder pump, etc.): �C,�ZX/� �,.,�t" <br />Vt�lierc� u�as th� ��vicc insl�lled (general description, altach map)? �/� rY.��,��(� _�:5�/�_C_l�. <br />Was there any other sewer or slorm drainage v�nrk cnmpleted in conjuncl/ i� wilnti Ihe DN10 work? Is so please describe: __ <br />–1 i� '�— <br />Installation Checklist: <br />Are all dovenspouts and site drainage disconnecled (rom upstream of Ihe DWD? ,�' es ❑ No Comments: _ <br />Does NWD posilioning mcets minimum slope requirement of >1 °67� Yes [� No Commenls: _. <br />Can BWD be puiled oul for inspection and maintenanr.e a(ler looseniny thumh screw- ,[)-Yes ❑ No <br />Is BWD locked into ihe ropecposili�n and ihumb screw lightened? �'Yes ❑ No <br />Grcle the BWD cov : irrigalion cover (laf�dscape area) I irai(is load beariny eover (drive suAar.e) I access halch (building) <br />Was property owner shown Ihe localion of the installed BWD?�Yes ❑ No Commenis: _ _ <br />� � �^ �/� <br />Properly Owner's Signaturc: .�l'�p-_. L�%�� � _ Date: � <br />InstallersSignature.� ---- -- ��1e' S` �5-_— <br />Rrvi ;ion: 7 1 Friday, September 12, 2014 <br />