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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: —' t"j r <br />Date Backwater Prevention device (BWD) was installed- l0-2-2) •- /S Date ih <br />Installation Property Owner Name and Contact Info: J <br />Property Address: 3 <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation <br />form was completed:/t7—a/— <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? KYes 0 No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? flea ❑ 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? Kl 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? QYes []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? R[Yes ❑ No <br />Installation Details: r <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): [ ��,4 A _ �"r r ,/V <br />Where was the de ice in§called eneral description, attach map)? Q-P— Q �, ram_ <br />n 11�1�1 �t12(L &=!q <br />Was chore any other sewer or storm clAinage 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? &Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? 0 Yes ❑ No <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? <br />Is BWD locked into the proper position and thumb screw tightened? 0 Yes ❑ No <br />Comments: <br />0,Yes ❑ No <br />Circle the BWD cover: irrigation cover (landscape area) t traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? JqYes ❑ No Comments: <br />Properly ( <br />Installer's <br />Revision: 2 <br />`O- zi -/.f <br />/O_ 2/—/S <br />Friday, September 12, 2014 <br />