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4, BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: t-62.0 PLJ3w%c3i0-0Le .240t0--40k -cfi2-5 <br /> Date Backwater Prevention device(BWD)was installed: IO— l "»/T Date this form was completed: /0 —/4 <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?21 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? gYes ❑No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? R.Yes ❑No Describe: <br /> Have all building 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? El Yes ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? i; Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): etelq <br /> Where was the device installed(general description,attach map)? <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? IN Yes ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? 21 Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? J I Yes ❑No <br /> Is BWD locked into the proper position and thumb screw tightened? fl Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the location of the installed BWD? Vj Yes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature: t--- -y— Date: 0— /o -. r'yf <br /> Revision:2 1 Tuesday,September 16,2014 <br />