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OLBACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Pi,•'renlion device (BWD) was installed: Date this form was completed: <br />Installation Property Owner Name and Contact Info: _ (70,-c I e If u ^ Ll ,2 3a &�u-7q <br />Property Address: _ % I S (7'n., e' #,-, <br />Pre•installation Inspection Checklist: <br />All items must be chec,. �d'Yes' in order fora BIND to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? EtYes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? [Yes []No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? OYes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sever TV inspected from building to sewer main? ® Yes ❑ No Condition: In t c— A puce. Scru LPS <br />Does side sewer have at least 1% slope from the building to sewer main? ©Yes ❑ No Describe: <br />Have all buiding sewer drain connections to the side sewer been identified and located? R Yes [--]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 ❑ No <br />Installation Details: <br />What type and brand of BWD was .stalled at this site (Clean Check BVVV, Grinder pump, etc.): C Icy c /� e 1, _ <br />Where was the device installed (general description, attach map)? Ryi-u,\C" DF A b w-t 6,\ �o.i� <br />Was there any other sewer or storm drainage wcrk 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? JK Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? RrYes FIND Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? El Yes ❑ No <br />Is BIND locked into the proper position and thumb screw tightened? RYes ❑ No <br />Circle the BWD cove:i igation co landscape area) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? ®Yes ❑ No Comments: <br />Property Owner's Signature: Date: <br />Installer's Signature: Date: <br />Revision: 2 <br />I— Ci—I S <br />Monday, September 15, 2014 <br />