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BACKWATER PREVENTfON DEVICE FINAL <br /> � INSTALLATION CHECKLIST <br /> ���� <br /> instafEation Company Name and Contact Info:��p�, �,�,,�Q�-`tC. � ���'�f��l-l-� �t��C?�._� ' <br /> Date Backwater Prevention device {BWD)was installed:�•j���y �((r�� Date this form was completed: [ <br /> Installation ProperEy Owner Name and Contact}nfo: ��:�,���'��j�1 �j � R���,��� �-L�(��g' <br /> Property Address: �Q� � ,�� <br /> Pre-Installation Inspection Checklist: <br /> Alf rtems must be checked`Yes'in order for a BWD to be consrdered for insfallafion <br /> Is there a basemenf or level of the house that is at or near assumetl sewer main elevation? �iYes ❑ Na <br /> Are there fixtures in fhe house located below the upstream sewer manhole rim elevation? (�Yes ❑ No <br /> 4s the side sewer currently 11NPROTECTED from sewer backups (does not have a BWD installed)?�Yes ❑ No <br /> Site Inspection Checklist: <br /> A1f ifems musf be checked`Yes'befare inspectron is consrdered complete <br /> Was side sewer TV inspected from building to sewer main? ❑ Yes �No Condi#ion, ���(���(���� <br /> Does side sewer have at least 1%slope from the building to sewer main? �Yes ❑ Na Describe: <br /> Have all building sewer drain connections to the side sewer besn identi€ied and located? �Yes ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? �'Yes ❑ No <br /> Has property been evaEuated for drainage deficiencies with findings cornmunicated to property owner? �Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): r�'" i��,�� <br /> Where was the device ins#alied (general description, attach map}?`� ", -� � � <br /> � y, � <br /> Was there any other sewer or storm tlrainage work completed in conjunc#ion with the BWD work? Is so please describe:_ <br /> Instaliafian Checklist: � <br /> Are aEl downspouts and site drainage disconnected from upstream of the B►ND? ❑Yes ❑ No Cflmments: <br /> Daes BWD positioning meets minimum slope requiremenf o#>1%? ❑Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after laosening thumb screw? ❑Yes ❑ No <br /> Is BWD focked�nto the proper position antl thumb screw tightened? [] Yes ❑ Na <br /> Circie the BWD cover: irrigation cover(landscape area}1 tra�ic load bearing cover(drive surtace)/access hatch (building) <br /> Was property owner shown the location of the instalfed BWD? ❑Yes ❑ No Comments: <br /> � <br /> Property Owner's Signature: Dafe: <br /> Installer's Signature: Date: ���.j.(_�( �--.._ _ <br /> � <br /> Revision:2 1 Friday, September 12,2�14 <br />