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BACKWATER PREVENTIOM DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Into :—Ti P.0 1•cTU'_��.�Z`.i)�.---�---r <br />Date Backwater Prevention device (BWD) was installed:._ Date this formVascompleted:__ <br />Installation Property Owner Name and Contact In(o:6t_�:;_:_,.��, <br />Property Address: <br />Address: <br />Pre -Installation Inspection Checklist: <br />All items must be chocked'Yes' in order for a BWD to be considered forinstallation <br />is there abasement or level of the house that is at or near assumed sewer main elevation? [ZYes ❑ No <br />Are there fixtures In the house located below the upstream sewer manhole rim elevation? % Yes [:]No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? ["Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked'Yes' botore inspection is considered complete / <br />Was side sewer TV inspected from building to sewer main? Yes ❑ No Condition: <br />Does side sewer have at least 194 slope from the building to sewer main? ]MYes [:]No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? W Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? W Yes ONO <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [>-TYos ONO <br />Installation Details: - <br />What type and brand of BWD was installed at this site (Clean Check BIr/V, Grinder pump, etc.): 4o^mac--c L <br />Where was the device installed (general description, attach map)? �5f`f i:. l-Eyr('.ter{ k3 Rc 4 <br />Was them any other sewer or storm drainage work completed; n conjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Ara all downspouts and site drainage disconnected from upstream of the BWD? IyYos ❑ No Comments: <br />Does BVVD positioning meets minimum slope requitement of >l%? W Yes L] No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? 4 Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? W Yes [-]No <br />Circle the BWD cove(. irdgatlon cove�tlandscape area) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the_loc lion of the installed BWD? 1�1 Yes M No Conlmef�Ib k Is:1rh-'ri.S iV aU4 4 <br />t(1 r�Ut loci/ yl�{ Ell PKU(� nEd `i `if1O fCd riC:tgt'C,�15^ <br />Property Owners Signal _ � R �J t B�'�2�J Dale: �/ /z!r — <br />/ / t� <br />Installer's s Signature: �,' ��—' <br />Revision: 2 1 Friday, 5eptember 12, 2014 <br />