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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: i- 4p- 9Lta,'' ';' I "'(-' <br />Date Backwater Prevention device (BWD) was installed: lr? -1 t A. Date this form was completed: icr - <br />Installation Property Owner Name and Contact Info: <br />Property Address: <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 abasement or level of the house that is at or near assumed sewer wain elevation? ❑ Yes ❑ 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)? ❑ Yes ❑ 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? [AYes ❑ No Condition: I3 ,+ram <br />Does side sewer have at least 1% slope from the building to sewer main? ❑X Yes []No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? ® 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 installed at this site (Clean Check BWV, Grinder pump, etc.): C 1 i n �(' I[t r. i <br />Where was the device installed (general description, attach map)? ICY• 7/f S>Or c.i F, euE 13-c.k <br />&.?) h <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />S' nL<J ,� P- n[ f5 <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? [XI Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1 %? Rf Yes [_]No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? M Yes ❑ No <br />Is BWD locked into the proper position and thumb screw lightened? O Yes ❑ No <br />Circle the BWD cover: irrigation cover (landscape area) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of Walled . Pq Yes ❑ No <br />Property Owner's Signal <br />Installer's Signature: <br />Revision: 2 <br />Comments <br />Date: /e. — 3 — iy <br />Date: !v - 3 /;� <br />Tuesday, September 16, 2014 <br />