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i BACKWATER PREVENTION DEVICE FINAL <br /> * INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: 47 - P l4: b r 1 L._ > C✓4aZS /t4 l <br /> Date Backwater Prevention device(BWD)was installed:[42c, 1 fS `Zti Date this form was completed: ace_, 15 204 <br /> Installation Property Owner Name and Contact Info: Z t e_ <br /> Property Address: 2_S-1-lam OD rl&.-v- Yct..i <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? R s ❑No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Mks ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? (o-'fes ❑ 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? [tom§ ❑ No Condition: Sp rvvc_.he., 3 r. cep-CA'"-J <br /> Does side sewer have at least 1%slope from the building to sewer main? [ems ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? fq'Pes ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? [q-fgs ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ['fts ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): C ci-4- c1r14._ <br /> Where was the device installed (general description,attach map)? f<Vt_� �O c l v-ckc�-� cat <br /> L (A / cr - <br /> Was there a other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe:_ <br /> V <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? ©ems ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? aktr§ ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? IL-Yes ❑No <br /> Is BWD locked into the proper position and crew tightened? es ❑No <br /> Circle the BWD cover: irrigation cove (land pe area affic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? es ❑No Comments: <br /> Property Owner's Signature: rfrDate: / /6 - 7..-01 <br /> Installer's Signature: / % / !0 -ct Date: . L$ Z AAAA <br /> Revision: 2 1 Friday,September 12,2014 <br /> 7:i <br /> 3 <br />