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"IP BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: M pew Pkiri4i ''1) 5 7 OD -? <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: 1.a- o iy <br /> Installation Property Owner Name and Contact Info: Lc.c1 y G►'sk y _S S.S 1 U 3 <br /> Property Address: 2�-i I,.i�..y4, <br /> Pre-Installation Inspection Checklist <br /> All items must be checked`Yes'in order for 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?EI Yes ri No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?g Yes [1 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? ®Yes ❑ No Condition: I'1 <br /> Does side sewer have at least 1%slope from the building to sewer main? U Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? PKI Yes n No <br /> Have all property storm drainage connections to the side sewer been identified and located? 1 Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 1 j Yes n No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump, etc.): Cecy, (t- e c-/t <br /> Where was the device installed(general description,attach map)? he u�;.c (:.mac; s-1.4e) <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> A7/Ek <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? M Yes n No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? [k]Yes n No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? E1Yes 0 No <br /> Is BWD locked into the proper position and thumb screw tightened? g Yes 0 No <br /> Circle the BWD cover: irrigation cove (landscape area)I traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the location of the installed BWD? Q Yes 0 No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature: v/J '7 • �'^ Date: ' Z C 111 <br /> Revision: 2 1 Monday,September 15,2014 <br />