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, 1 <br /> 4.77 BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: c 5tit Phe/1 s P'4 G,h; 111 Ls) � � -3q 1 <br /> Date Backwater Prevention device (BWD) was installed: I) / ,3 ' ",/'/ Date this form was completed: / sr //e/ <br /> Installation Property Owner Name and Contact Info: r"; f 4i1 iC 4 rile L qzs) i .21-q2 <br /> Property Address: /4 o Cie"aly) 4 vp 4-vir'ej f R 20 1 <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?j Yes No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?A.Yes U No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? 14Yes 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? Yes U 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? ,T'Yes U No <br /> Have all property storm drainage connections to the side sewer been identified and located? 1\(j'Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ) 1'Yes n No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): dc-, e'6, c r� <br /> Where was the device installed (general description, attach map)? 0,4 S %�"a kQ <br /> Setv.er ac: T� <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br /> y5-c,.or f tA—e. roia., Ho., Y c / I <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? ` 1 Yes n No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? Yes No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? X Yes I I No <br /> Is BWD locked into the proper position and thumb screw tightened? 1 Yes n No <br /> Circle the BWD cover: irrigation cover(landscape area)I traffic load bearing cover(drive surface) /access hatch (building) <br /> Was property owner shown the location of the installed BWD? ,I Yes I I No Comments: <br /> Property Owner's Signatur Date is//o/i <br /> Installer's Signature' Date: /0 / /d//4 <br /> Revision: 2 1 Monday, September 15, 2014 <br />