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BACk�JVATER PREVENTION DEVICE FINAL <br /> INSTALI.ATION CHECKLIST <br /> Inslallation Company Name and Contact Into: M otn {�IU r�i����/ 4�S 76 U Sr36 0 <br /> Date Backwater Prevention device(BWD)was installed: Date this form tvas completed: �� -�1-��/ <br /> Installation Property Ovmer Name and Contact Info: r� Man b vc.n� S U"1 5 �G titi3� <br /> PropertyAddress: a�(� S� M4nn�e- S.{- h..cn.�-t wR <br /> Pre•Installation Inspection Checklisl: <br /> All items must be checked'Yes'in orcier for a BWD(o be considered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?]Yes ❑ No I <br /> Are there fixlures in the house located 6elow the upstream sevrer manhole rim elevation?�Yes ❑ No I I <br /> Is the side sewer currenlly UNPROTECTED from�evier backups(does not have a BWD installed)?�Yes ❑No ! <br /> � <br /> Site Inspe�tion Checklist: � <br /> All items must be checked'Yes'before inspection is considered complete i <br /> VJas side sewer N inspected from building to sewer main? [k]Yes ❑ No Condition: So� �.��S I <br /> Doe�side sewer have at least t%slope from the building lo sewer main7 �'Yes ❑ No Describe: <br /> Have all building setver drain connections to the side sewer been identified and located? �Yes ❑ No <br /> Have all properiy s;orm drainage connections to the side sewer been identified and located? �Yes ❑ No <br /> Has property been evalualed for drainage deficiencies vaith findings�ommunicated to property owner? �'Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was inslalled at this site(Clean Check BWV,Grinder pump, efc.): C�u-•� c 4 �k <br /> Where�vas the device installed(general description,attach map)? �qS� s�"L e o� �y,�� <br /> iv� k.�� va/� <br /> —� <br /> Was ihe�all�lher sewer or storm drainage work compleled in conjunofion with ihe 8WD work7 Is so please describe:_ <br /> � <br /> Installation Checklist: � <br /> Are all c�oti�nspouts and sile drainage disconnected from upslream of the BWD? �f Yes ❑ No Comments: � <br /> Does BWD positioning meets minimum slope requirement of>1%? '�]Yes ❑ No Comments:_ � <br /> Can BWD be pulled oul for inspeclion and maintenance afler loosening thumb screvJ� ?�3f 1'es ❑No � <br /> Is BWD locked into the proper position and thumb screw tightened7 �j'Yes ❑ No <br /> Circle the BWD cover. irrigalion cover(landscape area)I traffc load bearing wver(drive sudace)1 access hatch(building) ( <br /> Was property owner shown the location of the insfalled BWD? [ .�c Yes ❑ No Commenls: <br /> Property Owners Signature: Date: <br /> Installers Signalure: �I ✓. �_ Date: � ' q' � S <br /> Revision: 2 1 Monday, September 15,2014 <br />