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BACKWA�ER PREVENTION DEVICE FIN�4L <br /> INSTALLATION CHE�KLIST <br /> Installation Company Name and Contact Info:��� � �S - y� �- �/z <br /> Date Backv�ater Prevention device(BWD) was installed: [ 3� [�- Date this torm was completed: (21z c 3 -Z c� 5— <br /> Inslallation Property O�vner Name and Contacl Info: c�ii�a.vc.�-- �T►'Z.u�-{Vt�r 2Sg - y8 8� <br /> PropertyAddress: �C� ��T` � <br /> Pre•Installation Inspection Checklist; <br /> All ilems mus!be checked 'Yes'in order/or a B WD fo be considered(or ins!allafion <br /> Is lhere a basemenf or level of the house that is at or near assumed sewer main elevation? • es ❑No <br /> Are there fixlures in Ihe house located below ihe upsiream sewer manhole rim elevation7 [t��Yes ❑ No <br /> Is the side seerer curren�ly UNPROTECTED from sewer backups(does not have a BWD installed)? [a'Pes ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'be(ore inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main% �5 ❑ No Condition: dYll 9,��� L��-� � <br /> Does sida sewer have at leasl 1% slope(rom ihe building lo sewer main7 es ❑ No Describe <br /> Have all building sewer drain connections lo the sitle s���ver been identified and located7 [�fes ❑No <br /> Have all properly storm drainage connections to the side;:�vder been identified and located? �j�cs ❑No <br /> Has property been evaluated tor drainage defciendes ;�ith fin�ings communicated to property o�vner? [i}YSs ❑ No <br /> Installation Details: <br /> �Uhat type and brand of BWD�vas installed at this site Clean Check BW��, Grinder pump, etc.): �^L<<C ' <br /> Where was the devi�e installed (general descriplion, attach map?? ��Ge /1� t�a-,o _ <br /> Was there any other sewer or stortn drainage work completed in conjunclion wilh the B�ND v�ork? Is so pleas�r describe:_ <br /> �13v�-�C-— <br /> Inslallation Chocklist: ' <br /> Are all downspouls and sile drainage disconnected from upstream of the BWD? es ❑No Commenis: � <br /> Daes BWD positioning meets minimum slope requiremenl of>19a? [�}-Ye� ❑ No Comments: II <br /> Can BWD be pulled out for inspection and maintenance after loosening Ihumb screw? �`�s ❑ No <br /> is BWD locked inro the proper posilion an screw tightened7 D�s ❑ No I <br /> Circle the BWD cover:irrigation cov (landsca ; ue affic load bearing cover(drive suriace)1 access halch (building) <br /> Was property o�vner shown the location of the inslalled BWD7 es ❑ No Comments: <br /> Property Owner's Sig Date: CL2_c, 3 - 2 al 5 <br /> Installer's Signatur� Date: � 2- � �l- 0 i � i <br /> Revision:2 1 Friday, September 12, 2014 <br /> / <br />