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4:77 BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: 14 Q('.n P/Li.ti hilt L'ac .7(,v g--7 0 <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: <br /> Installation Property Owner Name and Contact Info: Joe '(`, f e y 30). 3 7 3 i3Lt S <br /> Property Address: l o U LJ % z v <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 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?E]Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? ©Yes E 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? [?c]Yes ❑ No Condition: &-co S J' tL_ <br /> Does side sewer have at least 1%slope from the building to sewer main? 1 Yes n No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ®Yes 0 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 n No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): /7k S <br /> Where was the device installed(general description,attach map)? fin he cv yr /ac <br /> Was there a other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> � <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? J 1 Yes n No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? 1 Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ❑Yes n No <br /> is BWD locked into the proper position and thumb screw tightened? n Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)I traffic load bearing cover(drive surface) cess had uilding) <br /> Was property owner shown the location of the installed BWD? 21Yes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature: %-4 7 'e---- Date: I " a2- I s <br /> Revision:2 1 Monday,September 15,2014 <br />