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• <br /> 47, - BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: 00 t b Y (LXX ra t h <br /> Date Backwater Prevention device(BWD)was installed: °(.11-( (( C Date this form was completed: ft 9 /15— <br /> Installation Property Owner Name and Contact Info: 1-.\-0kitt( Frkkiat\ i6k4 <br /> Property Address: U`�.-- lM(boLA( C \i J L <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD fo be considered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?( ]Yes ❑No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD I stalled)? Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered mplete <br /> • <br /> we <br /> Was side sewer TV inspected from building to sewer main? Yes 0 No Condition: <br /> Does side sewer have at least 1%slope from the building to s. r main? Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [7]Yes 0 No <br /> Have all property storm drainage connections to the side sewer been identified and located? [7 Yes 1771 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? .0 Yes ❑No <br /> Installation Details: _---- <br /> What type and brand of BWD was installed at this sit= Clean Check ; i"+,Grinder pump,etc.): . <br /> Where was the device installed(general description,attach map)? PG &J i d of (..G4 <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? d Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? Yes 0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosen ng thumb screw? ( ]Yes ❑No <br /> • <br /> Is BWD locked into the proper position and thumb scrag ti•htened? 0 Yes 0 No <br /> Circle the BWD cove , irrigation covet(landscape area)I traffic .1d bearing cover(drive surface)I access hatch(building) <br /> Was property owner shown a 'en-ef-the install-2 :i,. lEn Yes 0 No Comments: <br /> • <br /> Property Owner's Signature: �- Date:Date: <br /> Installer's Signature: .14 <br /> . . <br /> Revision:2 1 . Friday,September 12,2014 <br />