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0-1477. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: t4 Oe" el"r•-•b <br /> Date Backwater Prevention device(BWD)was installed: '1 O—i ( Date this form was completed: 6-/O–i C <br /> Installation Property Owner Name and Contact Info: ,7o fry Le— ( 3141 — 5-67 <br /> Property Address: <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD to be considered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?E Yes 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?in Yes ❑No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)'? E Yes 0 No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? E Yes ❑No Condition: !117 d t pf nor/ 1 <br /> Does side sewer have at least 1%slope from the building to sewer main? Et Yes 0 No Describe: <br /> Have ail building sewer drain connections to the side sewer been identified and located? f2 Yes ❑No <br /> Have ail property storm drainage connections to the side sewer been identified and located? E Yes Q No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ,j Yes [] No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): 'CO1% 2- <br /> Where <br /> Where was the device Installed(general description,attach map)? belt . J vimf c*-.'rS <br /> Was there anyother sewer { <br /> or storm drainage/tor a�+arwork? <br /> g completed in conjunction with the BWD Is so please describe: <br /> !v• <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? EZ Yes 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? o Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ❑Ye o <br /> Is BWD locked into the proper position and thumb screw tightened? Y o l <br /> Circle the BWD cover:irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the location of the installed BWD? 'Yes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> installer's Signature: rC1 l^ Date: ` (0— <br /> Revision:2 1 Monday,September.15,2014 <br /> 3 <br />