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477. <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: APB//� rbt,v7 3Gel <br /> Date Backwater Prevention device(BWD)was installed: S/,7I/ Date this form was completed <br /> Installation Property Owner Name and Contact Info: /Lick 5- -1 r n7, <br /> Property Address: %el z7 foe-,50,7,0 <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? p Yes 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?4 Yes 0 No <br /> Is theside sewer currently-UNPROTECTED from sewer backups(does not have a BWD installed)?,e]Yes 0 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? Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identifie and located? `91/Yes ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? A Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? WYes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): <br /> Where was the device installed (general description,attach map)? l' D®l % cc'e cc- <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe: <br /> ,4,.E <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? Yes 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? 4 Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ,`Yes 0 No <br /> Is BWD locked into the proper position and thumb screw tightened?e'Yes ❑No <br /> Circle the BWD cover irrigation cover(landscape area)I trail g cover nve su )I access hatch (building) <br /> Was property owner shown the cation of the installed BWD? fes 0 No Comments: <br /> Property Owner's Signatur • ' nA Q-s— Date: Z/L// /,S <br /> Installer's Signatur • --a-- Date: Z/4///S"' <br /> Revision:2 1 Friday,September 12,2014 <br />