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/ JJr <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Amer-`can -i c,J * 5 t 1_LC <br /> Installation Company Name and Contact Info:-e cc Qi-Cf:« :5) 54qJ(T i vrk'c i4) qo 3 9, <br /> Date Backwater Prevention device(BWD)was installed: \I 141(5 Date this form was completed: 1.1(411.5 <br /> Installation Property Owner Name and Contact Info: '3b Y\ AtIrierSeil ,c 1Z - 6- a 6 ?--4& o <br /> Property Address: a3ca elc, Ver _ + ' "e c ac t <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 E 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 installed)? ( Yes ❑ 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? KJ Yes 0 No Condition: ct <br /> Does side sewer have at least 1%slope from the building to sewer main? p33 Yes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? cgl Yes 0 No <br /> Have all property storm drainage connections to the side sewer been identified and located? t1 Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? EX Yes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): cke(46r $i <br /> Where was the device installed(general description, attach map)? 6 C a±fackQd As Ka;,( C' <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe:T <br /> Om Q <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? 4-Yes 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? KYes (1 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? Z Yes 0 No <br /> Is BWD locked into the proper sosition and thumb screw tightened? ' Yes 0 No <br /> Circle the BWD cov-. irrigation cover landscape area)I traffic load bearing cover(drive surface)I access hatch (building) <br /> Was property owner s own the loca'on of the installed BWD? J Yes 0 No Comments: <br /> r*.x OP Property Owner's Signatur . ., ,vj I C ,ka-- -2 5 R, Date: q /5 <br /> Installer's Signature: fi Date: kl (+ /5 <br /> 1 Or <br /> Revision:2 1 Friday,September 12,2014 <br />