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BACKWATER PREVENTION DEVICE FINAL <br />4.7-F INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: A OY CI Cr? 1-1 ` ',lit lc °i :7trlr 7F .c <br />t <br />Date Backwater Prevention device (BWD) was installed: ��_ Date this form was <br />Installation Property Owner Name and Contact Info: Lurii Ile <br />Propedy Address: (, ( �'• <br />Pre -Installation Inspection Checklist: <br />Alf items must be checked 'Yes' in order for a BV✓D to be considered for installation <br />Is there a basement or level of the hnuse 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? R Yes []No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BVdD installed)? Q'Yes LINO <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? P Yes ❑ No Condition: 7hlc� <br />Does side sewer have at least 1%slope from the building to sewer main? F <br />A Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? [�d 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? Eyes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): 2eC;76( <br />Where was the device installed (general description, attach map)? e rt k4 r'.r'i)1 ]� 'N <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br />Nt AQ — — <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? (JKYes <br />Does BWD positioning meets minimum slope requirement of >1 %1 14 Yes []No <br />❑ No Comments: <br />Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? I] Yes []No <br />Is BWD locked into the piopostion and thumb screw lightened? 0Yes ❑ No <br />Circle the BWD cw r irrlgatl11 cover la dscape area) I haffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? [P Yes ❑ No Comments <br />Property Owner's Signature. I Date: <br />P_' Date: <br />Installer ' 5 Signature: igeRevisio: 2 (/ 1 Friday, September 12, 2014 <br />