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BACKWATER PREVENTION DEVICE FINAL_ <br />Ev TT INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) was installed:_I, 1 _ Date this form was completed. <br />Installation Property Owner Name and Contact Info GU' Q U(.iCi <br />Property Address: I Iy2 63K6 y A &,i <br />Pre -installation Inspection Checklist: <br />All items must be checked 'Yes'm 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? (XI Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? N Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? to 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? N Yes ❑ No Condition; <br />Does side sewer have at least 1%, slope from the building to sewer main? [� Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? ® Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? U Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? R Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): Q VUQk <br />Where was the device installed (general description, attach map)? b_Lk J S12Ln V (El A � CLA- <br />f %I C -ice i v-/"/l 1AC•. L `._ <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? LYJ yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? [4 Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? Wes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? o Yes ❑ No <br />Circle the BWD cover: i ' ation cover landscape area f traffic load bearing cover (drive surface) f access hatch (building) <br />Was properly owner shorn the location of t ' stal ed BWD? XJ Yes ❑ No Comments: <br />Property Owner's Signature: J Date: � L <br />exP%unJ - I r <br />� <br />Installer's Signature: �f?��cP Date: I <br />Revision: 2 1 Friday, September 12, 2014 <br />