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BACKWATER PREVENTION DEVICE FINAL <br />E� INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: _ �? -'!�9% - 7 /0 5r <br />Date Backwater Prevention, device (BWD) was installed:.=� ` / S__ DAh: Ihl$ fe1111 WiiS COIn(IICI(?d� 5 <br />Installation Property Owner Name and Contact II>E2^ - <br />Property Address:;�Ct 3 l GrEOtrr`D3 l �E/trr`D <br />Pre -installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered rorinslallation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? I_�,Kes [) No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? I -;.-'?es [] No <br />Is ine side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [v Yes F] No <br />Site Inspection Checklist: <br />Allitems must be checked'Yes'before inspection is consideredcomplete <br />Was side sewer TV inspected from building to sewer main? E✓rYes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? I._�Yos (__ I No Describe: <br />Have all building sewer drain connections to the side sewer been identified and Incated? J Wes [.] No <br />Have all property storm drainage connections to Ilse side sewer been identified and located? [.�rYies ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? r"rYes I1 No <br />Installation Details: <br />What type and brand of BIND was installed at this site (Clean Check BWV, Grinder pump, etc.) 6i -Ar/ G'!Eer- <br />Where was the device installed (general descripticn, attach map)?O lF4 <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br />N() <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? FR"Fes I_.I No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? f-tY'es ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? [ Yes I I No <br />Is BLND locked into tl�e proper_po5itio�and thumbscrew tightened? [r'f Yes I. j No <br />Circle the BWD cove i .igation (landscape area) / traffic load bearing cover (drive surface) / access halch (building) <br />Was property owner shown the location of the installed BWD? EJ/Yes D No Comments: <br />Properiy0wner'sSignatur _ ! Date:. <br />lnslallcrs signature -- /L -- �- `� _ Dale: _(y 1 / . . <br />Revision: 2 1 Monday, SvIM-mbor Ili, 2014 <br />