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BACKWATER PREVENTION DEVICE FINAL <br />00 INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: CJs PLUMBING & SERVICE LLC 360-e91-5159 <br />Date Backwater Prevention device (BWD) was installed: --I 1-1 5-- Date this form was completed: Tls-- [�, <br />Installation Property Owner Name and Conlayt Info: <br />Property Address: <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? © Yes ❑ No <br />Are [here fixtures in the house located below the upstream sewer manhole rim elevation? ?❑C 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' before inspection is considered complete �1 <br />Was side sewer TV inspected from building to sewer main? M Yes ❑ No Condition: G) <br />Does side sewer have at least 1% slope from the building to sewer main? V Yes ❑ No De.;cribe: <br />Have all building sewer drain connections to the side sewer been identified and located? [Yes ❑ No <br />Have all properly storm drainage connectiw,..10 the side sewer been identified and located? M Yes ❑ 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.) r�S C uh r <br />Where was the device installed (general description, attach map)? haD.t1-0_1, r > RSA tj ', <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? KI Yes ❑ No Comments: %A <br />Does BWD positioning meets minimum slope requirement of >1%? U Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ❑ Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? M Yes [—]No <br />Circle the BWD cover: irrigation cover (landscape area) 11raffir. load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the <br />Property Owner's <br />Installer's <br />of the installed BWD? [7Yes ❑ No Comments: <br />Date: / 1Y 11.5 <br />Date: _ le —/r— <br />Revision: 2 1 Friday, September 12, 2014 <br />