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� BAC�NVATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: � <br />Date Back�vater Prevention tlevice (BWU) was installetl <br />Date this form ivas completed: �" 2-� S <br />Installation Properfy Owner Name and CoNact Info: `� l.n 1�, ,��rn %u` <br />PropertyAddress; I ��C�� ����c� S�' � ' <br />Pre-Installation Inspection Checklist: <br />Ail items must 6e checked 'Yes' in order for a BWD to 6e conside�ed (or installation <br />Is there a bssement or level of the house that is at or near assumed sewer main elevation? �Yes ❑ No <br />Are th2re fixtures in the house (ocated below the upsfream sewer manhole rim elevalion7 � Yes ❑ No <br />Is the side sewer currently UNPROTECTED irom sewer backups (does not have a BWD Installetl)? (�] Yes ❑ No <br />Site Inspection Checkiist: <br />A!I ilems must 6e checked'Yes' before inspecfion is considered compiete <br />VJas side sewer N inspected from building to setver maln? [� Yes ❑ No CondiHon: <br />Does side sewer have at least 1% slope from the building to setver main? �j Yes ❑ No �escribe: <br />Have all building sewer drain connecfions to the slde sewer been identifed and located? (� Yes � No <br />Have all property storm drainage connections to ihe sid: sevrer been idenGfied and located? [� Yes ❑ No <br />Has properfy been evaluated for drainage deficiencies wilh findings r,ommunlcaled to properry owner7 � Yes ❑ No <br />Installation Details: <br />What fype and brand of BWD v�as installed at this sit <br />Where was the device installed (general description, <br />Was there any other set�+er or slorm drainage work <br />Check BWV, �Pinder pump, <br />in wnjunclion wilh the BVJD vJork? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage dlsconnecled irom upstream of the BWD7 �Yes ❑ No Commen�s: <br />Dues BWD posilioning meets minimum slope requirement of>1%? �] Yes ❑ No Comments: <br />Can BWD be pulled out for in�pection and maintenance afler loosening thumb screNf? [/] Yes ❑ No <br />i <br />Is BWD locked into the prope�position-ancHhamb�serew tightened7 �{] Yes ❑ No <br />Cirde the BWD cover irrigalion rover (landscape are�! traffic load bearing cover (tlrive surface) I access halch (building) <br />Was property owner shown the localion.of.the-install d BWD? �j Yes ❑ No Commenls: <br />Property Owner's Signafure: _ Dale: <br />Instaliers Signature: Date: �> � �--�- / <br />Revision: 2 �`-� 1 Friday, September 12, 2014 <br />