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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact info:)C,Ge aj ce�_A? 0 - XL 5r/ �% N,, lAi ' &' —q <br />Date Backwater Prevention device (BWD) was installed:% I ,T �_ Date this form was completed: l (n <br />Installation Property Owner Name and Contact Info: "C' YI G <br />C� /��rJ'�S <br />Property Address: 1 L1 to �� Tom' L-_—��a��'l <br />Pre -Installation Im pection Checklist: <br />All items most be che,.lted 'Yes' in order for a BWD to be cons dered for installation <br />Is there abasement or level of the house that is at or near as: umed sewer main elevationYes (I No <br />Are there fixtures in the house located below the upstrram sever manhole rim elevation? Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer back fps (does not have a BWD installed)? [Yes ❑ No <br />Site Inspection Checklist: <br />All items most be checked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? ❑ Yes N No Condition: L ,n <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? g Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? DaYes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? ,® Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? <br />Was there any other sewer or storm drainage work completedinconjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? M Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Yes rj No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? [Yes [:]No <br />Is BWD locked into the proper 1 <br />Circle the BWD cover."irrigatto` <br />Was property owner shown the <br />*rcperty Owner's Signature: <br />Installer's Signature: <br />and thumbscrew tightened? Wes ❑ No <br />area) I traffic load bearing cover (drive surface) I access hatch (building) <br />of the installed BWD? ] Yes El No Comments: <br />Date: <br />Dater <br />Revision: 2 V 1 Friday, September 12, 2014 <br />