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BACKWATER PREVENTION �IEVICl= FINAL <br />J ' INSTALLATION CHECKLIST" <br />Installation Company Name and Contact Info-3 Cc Qi �f:(49�) rrlx C2`r - N <br />Date Backwater Prevention device (BWD) was installed:_— Date this form was completed:9� <br />Installation Property owner Name and Contact Info: <br />g <br />Address: ''' t Aix; <br />Proper:; � <br />Pre -Installation Inspection Checklist <br />All items must be checked 'Yes' in order fora BIND to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? RYes ❑ 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)? [AYes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete I <br />Was side sewer TV inspected from building to sewer main? RYes ❑ No Condition:&bbd — <br />Does side sewer have at least 1 % slope from the building to sewer main? [RYes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? P Yes ❑ 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? RYes ❑ No <br />Installation Details: <br />What type and brand of BWD was. installed at this site (Clean Check BWV, Grinder pump, etc..):: 9 <br />Where was the device installed (general description, attach map)? -:50—P /1 te + <br />Was there any other sewer or storm drainage work complete 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? (;3,Yes []No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Yes (-]No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? [Yes [] No <br />Is BWD locked into the pro sition and thumb screw lightened? Ryes ❑ No <br />Circle the BWD cover' rigation cover (la dscape aree) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner n of the installed BWD? pyes ❑ No Comments: <br />Property Owner's Signature: _ Dale: 2? ��- <br />Installees Signatu Date: <br />Revision: 2 1 Friday, September 12, 2014 <br />