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BACKWATER PREVENTION DEVICE FINAL <br />E� Tr INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />71/0 5 <br />/- <br />Dale Backwater Prevention device (BWD) was inslalled:e�o� / 5 _ Datc. This loon wss complelcd: <br />Installation Property Owner Name and <br />Contact Info: _ y�tJ%Z121 <br />Property Address: <br />Pre•Insta!lation Inspection Checklist: <br />All items must be checked 'Yes' m order for a BWD to be considered for installation <br />Is there abasement or level of hre house that is at or near assumed sewer main elevation? []'Yes []No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? I." !'Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? I-i frYes 1_J No <br />Site!nspeclion 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 I] No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? [+J1es I_J No Describe: <br />Have all building sewer drain connections to the side sewer been identified and localed? [�] Yes I_i Nu <br />Have all property storm drainage connections to the side sewer been identified and located? I.;� Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? 1; 7' s I ] No <br />Installation Details. <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? N,_ 51 ud" <br />Was there any other sewer or slorrn 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? (-.d Yes f ] No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? f—IfY-es f ] No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? I"[Yes I I Nu <br />Is BWD locked into the proQer.pD3L0Srand thumb screw tightened? [-V'ryes 1-.-]No <br />Circle the BWD col, irrigation cover (landscape area) / traffic load be cover (drive surface) / access halch (building) <br />Was property ownc�rshown the location of the installed BWD? Ines n No Comments: <br />Property Owner's Signature . _ _ _ Date:. <br />Installer':; Signature ,_ �'- _ _ DalcA,/%// Sr . <br />Revkiow 2 t Monday, Svptcrnbrr I Is, 2011 <br />