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,i4 BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> installation Company Name and Contact Inf i5v4e amii Lo,k iekice-5 ' .9--c9 21 ifQ <br /> J q r- <br /> Date Backwater Prevention device (BWD) was installed: 5( 7®-( /5 Date this form was completed: _/ /27/5 <br /> Installation Property Owner Name and Contact Info: ic-t -e(145K-1 Lies—-06)b -- 49e,37 <br /> Property Address: 19/1 ) t I T I <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? I I._i No , <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? [ Yes [ J No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [1es f21 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'? [9 Yes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? [ 'Yes ri No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [, Yes I ) 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 installed at this site(Clean Check BWV, Grinder pump, etc.): L _A' 61-fie e e <br /> Where was the device installed(general description, attach map)? I- o ppr 4 6- !i a $--.5M- e.- <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? R/es I I No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? [1 [- ( No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? I <Yes I I No <br /> Is BWD locked into the proper position and thumb screw tightened? I'--- es [ _.] No <br /> Circle the BWD cover: irrigation cover(lands ape a ea)/traffic load bearing cover (drive surface rc c ss h 3ic,h (building <br /> Was property owner shown the location / the in ailed WD? [' s l No Comments: <br /> Property Owner's Signature: 1 -----_ -- Date: 1/47// <br /> ) • <br /> Installer's Sicln ituo: �, = — — Dale:: 9�Z ' `�5-" <br /> / / <br /> Revi,,iun: -' I Mofddy, `,c,H1_,nil,( i 1',, ,'o1.1 <br />