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OLBACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Into: da, &Ltu ?1!s - 207- /SD7 <br />Date Backwater Prevention device (BWD) was Installed: Date this form was completed: <br />Installation Property Owner Name and Contact Info: <br />Property Address: <br />Pre-Insfallallon Inspection Checklist: <br />AA 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 ❑ No <br />Are there fixtures in the house located bellow 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' befom Inspection is considered complete <br />Was side sewer TV Inspected from building to sewer main? 0 Yes []No Condition: <br />Does side sewer have at least 1% s4e from the building to sewer main? []Yes ❑ No Describe: <br />Have all t.uildina sewer d,min oonnedrans to the side sewer been identiued and located? ©Yes ❑ No <br />Have 0 property storm drainage connections to the side sewer been identified and located? RJYos ❑ No <br />Has property been evaluated for drainage deficiencies %vith findings communicated to properh owner? Q Yes []No <br />installation Details: <br />What type and brand of BWD was Installed at this site (Clean Check BWV, Grinder pump, etc): <br />Where was the device installed (general description, abash map)? <br />Was there any other sewer or stone 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? ® Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >19V [ yes ❑ No Comments: <br />Can BIND be pulled out for inspection and maintenance after loosening thumbscrew? R Yes ❑ No <br />Is BWD locked into the proper poi and thumb screw lightened? OYes ❑No <br />Circle the BWD cover: Irrigation cover (landscape area) I traffic toad bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? ®Yes ❑ No Comments: <br />i <br />Property ovmoi s S1gnatuur4; '-/C OCc Date: -AT�_ <br />Installers Signature: d .ems s _ Dale: <br />Revision: 2 1 Friday, September 12, 2014 <br />