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BACKWATER PREVENTION DEVICE FINAL <br />4ZE77- INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: 1(�iCd'�`r<w rvr 7 <br />Date Backwater Prevention device (BWD) was installed:_�_416 _ Date this form was <br />Installation Property owner Name and Contact Info: <br />Property Address: <br />Pre -Installation Inspection Checklist: <br />All items must he checked 'Ye. in order for a BVJD to be considered for installatic n <br />Is there a basement 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 server manhole riin elevation? (_ Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? VYes ❑ No <br />Site Inspection Checklist: <br />All items must be crocked 'Yes' before inspection is considered complete <br />Was side sets,er TV inspected from building to sewer main? (Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? (XYes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? (Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? [Res ❑ 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.;: �e(_ i nr Seen,. V <br />Where was the device installed (general description, attach map)? SP.P-CiW_d_A_ <br />Was there any other sewer or storm drainage work completed in conjunction with the BIND work? Is so please describe: <br />Installation Checklist: <br />Are all downspouts and site drainage discoTirmrled from upstream of the BWD? Wes ❑ No Comments: <br />Does BWD positioning meets minim m slope requirenient of >1 %? F Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? KYes ❑ No <br />Is BWD locked into the proper posit,on and thumbscrew tightened? 9-Yes []No <br />Circle the BWD cove : inigafl cov r andscape area) / traffic load bearing cover (drive surface) / access hatch (building) <br />Was properly owner she a location of the installed BWD? (Yes ❑ No Comments: <br />Property Owner's Signatures Date: Is <br />Installer's Signature: _ Date: q16 I L5 <br />Revision: 2 1 Friday, September 12, 2014 <br />