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BACKWATER PREVENTION DEVICE FINAL <br />4W77- INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: IM221�i- <br />Date Backwater Prevention device (BWD) was installed: 6 1 Date this form was completed: <br />Installation Property Owner Name and Contact Info: ii.c� //.o 5. na,-1� <br />Property Address: 3Z?.u�-z i3aiQ <br />Pre•Instaliadon Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? ['Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation?�z Yes ❑ No <br />Is the sine sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?X1 Yes []No <br />Site Inspection Checklist: <br />All Berns must be checked'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? Vj Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? Z Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? Z 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? VYes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): /4& 13V✓1." <br />Where was the device installed (general description, attach map)? in 6-e fe P f pie f — <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is sc please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? QNes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of>1%? [Yes ❑ No Comments: <br />Can :.`,ND be pulled out for inspection and maintenance after loosening thumbscrew? JV1 Yes []No <br />Is BWD locked into the proper position and thumb screw tightened? V Yes ❑ No <br />Circle the BWD cover: jpigas c2vP� tl scaoe areall Uaffic load bearing cover (drive surface) I access hatch (building) <br />Was propa,ly owner shown the <br />Property Owner's <br />Installers <br />Revision: 2 <br />the installed BWD? 7Yes ❑ No Comments: <br />Date: �i/'? <br />Date: 51;4 rl,[/� <br />Friday, September 12, 2014 <br />