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, , , ' 4.77. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: C=RO itoiv 13'NJ c.0 <br /> Date Backwater Prevention device (BWD)was installed: '5— ! --11 Date this form was completed: 9—/7 . /1 <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 a basement or level of the house that is at or near assumed sewer main elevation?ix Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?(Y1 Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? 2 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? 54 Yes ❑ No Condition: 0 V- <br /> Does side sewer have at least 1%slope from the building to sewer main? ( J Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? L Yes ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? N(Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 23 Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): Cl mJ el-leek: <br /> Where was the device installed (general description,attach map)? it/orit,e,i S",0,-,-- d 6 ZAi',ie." <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe:NO <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? E Yes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? 1 Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ®Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? M Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)I traffic load bearing cover(drive surface)t cess hatc)(building) <br /> Was property owner shown the locals' '... I-. : , . X Yes ❑ No Comments: <br /> Property Owner's Sign. . e• �� Date: 9 t 0 <br /> Installer's Signature: _ - — Date: ` if /- <br /> Revision:2 1 Tuesday,September 16, 2014 <br />