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BACKWATER PREVENTION DEVICE FINAL <br />4L INSTALLATION CHECKLIST <br />f'►1Eri ccen Eq t c� ^+ side : e.�a:y-, L LC <br />Installation Company Name and Contact In1o:5� �� ' <br />J <br />Date Backwater Prevention device (BWD) was installed:3 Jol 115 Dale this form was completed: d <br />Installation Fropeity Owner Name and Contact Into: 1JanJ. LdL11,1,r D21,Q 4,3,,--403 - <br />Property Address: <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BWD to be considered for installation <br />Is there abasement or level of the house that is at or rear assumed sewer main elevation? 0 Yes [)No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? EP 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? 0 Yes ❑ No Condition: 6�7 <br />Does side sewer have at least 1% slope from the building to sewer main? g Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? MfYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? [Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BINV, Grinder ump, etc.): <br />Where was the device installed (general description, attach map)? ',.)eL'-6 AS� r1 <br />Was there any other sewer or storm 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? E%Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >l%? 54'Yes ❑ No Comments: <br />Can BWD be pulled out for Inspection and maintenance after loosening thumbscrew? [PNes ❑ No <br />Is BWD locked into the propec{wsi ion and thumbscrew lightened? [1 es ❑ No <br />Circle the BWD coti c urigation wver andscape area) / traffic load bearing cover (drive surface)/ access hatch (building) <br />Was properly owner <br />Property Owner's <br />Installer's Signature: <br />installed BWD? [Wes ❑ No Comments: <br />Date- t 02,0 ._1 / <br />Dale: 5 i <br />Revision: 2 - <br />I/" 1 Friday, September 12, 2014 <br />