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BACKWATER PREVENTION DEVICOr F21129 <br /> # 1 <br /> INSTALLATION CHECKLIST 1‘k Ai <br /> IPYT <br /> C WORKS <br /> Installation Company Name and Contact Info: \ \Unr\lry rck u C- <br /> - <br /> Date Backwater Prevention device(BWD)was installed: CS- Date this form was completed: <br /> Installation Property Owner Name and Contact Info: 1-4/.10.1e-kk WatUki <br /> Property Address: . bOLQ CfrNrir OtLiv\- <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? Yes flNo <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? 1-44Yes El No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?41 Yes n 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? 11P11. Yes 9 No Condition: <br /> Does side side sewer have at least 1%slope from the building to sewer main? IW. Yes C. No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? V, Yes El No <br /> Have all property stormdrainage connections to the side sewer been identified and located? 172 Yes No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 0 Yes E No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.):fliV-1> Ictwe,Where was was the device installed (general description, attach map)? 13141tn. FvLemA <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe .W <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? 71,Yes E No Comments: <br /> k <br /> Does BWD positioning meets minimum slope requirement of>1%? aYes 9 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? FXV'es n No <br /> Is BWD locked into the proper position and thumb screw tightened? 5KYes E No <br /> Circle the BWD cover: irrigation cover(landscape<area)I traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the locatp of the installed BWD? 17-Yes Fl No Comments: <br /> Property Owner's Signature ./1. Date: "3&. lb <br /> Installer's Signature: 2.4.7,0 :i Date: Nu. ( <br /> Revision:2 1 Friday,September 12, 2014 <br />