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BACKWATER PREVENTION DEVICE FINAL <br />r -E� INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: l AJTN F6-'ILt'� iL-limn 6 J r II r r\ <br />Dale Backwater Prevention device (BWD) was instailed:*� 0//T Date this form was completed: - ZU S <br />Installation Property Owner Name and Contact Info: /✓/� C ��1� .a c��_ _ _ <br />Property Address: <br />w <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 bi�_ement or level of the house that is at or near assumed sewer main elevation? I�Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? [ Yes ❑� NN <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? I� Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked'Yes' before inspection is considered co plefe <br />Was side sewer TV inspected from building to sewer main? Yes ❑ No /Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? 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? Bles ❑,�__.,,/NNo <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? � Yes ❑ No <br />Installation Details: <br />What type ana brand of BWD was installed at this sit (Clean Check BWV, tinder pump, etc.): <br />Where was the device installed (general descriptio attach map __r¢ <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br />Installation Checklist: 7 cif '%••0•4" `*^-0/4,4e„ w¢ // <br />Are all downspouts and site drainage disconnected from upstream of the BWD? [j� es ❑ No Comments:____ <br />Does BWD positioning meets minimum slope requirement of >19A? [ e's ❑ No Comments: <br />Can BWD be pulled out lot inspection and maintenance after loosening thumb screw? Yes ❑ No <br />Is 13WD locked Into the proper position and thumb screw tightened? Wes ❑ No <br />Circle the BWD cover. irrigation cover (landscape area) I traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of the installed BWD? [eles ❑ No <br />�J <br />\ Property Owner's Signature/, z /r' 4✓%4 <br />Installer's Signature: , G>/r�{� r . A' ic_% Z <br />Comments: <br />Date: ?_k �y✓/.� <br />Dale:/ / S <br />\ Revision: 2 1 Monday, September 15, 203.4 <br />