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BACKWATER PREVENTION DEVICE FINAL <br />4--7T INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: fjhGi/U 2L&"131d 4 <br />Date Backwater P.avenUon device (BWD) was installed: " / Date this form was completed: � /L <br />Installation Property Owner Name and Contact Info: L'IelpLS�=ni <br />Property Address: Ac-1;'c.w/ <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 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 sewer manhole � ur elevation? Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? Z Yes ❑ No <br />Site Inspection Checklist: <br />All items must be chocked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? P Yes <br />❑ No Cc.idition: <br />Does side sewer have at least 10% slope from the building to sewer main? <br />[7Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? 4 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? Z Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this sit can Check B �, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? ✓ Oh v-&Yy <br />Was there any other sewer or storm drainage work completed ii�conjunction � ith the BWD work? Is so please describe: <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? [ZYes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? P Yes ❑ No Comments: _ <br />Can MID be pulled out for inspection aid maintenance after loosening thumb screw? P Yes ❑ No <br />Is BWD locked Into the proper osilion and lhumbsc v tlghtened? [Yes ❑ No <br />Circle the BWD ver: imyaior over.(lands pe area) l traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the instal ed BWD? VI Yes ❑ No Comments: <br />Property Owner's Signature: I r ) _ Date: 3 -s <br />Installer's Slgnalura/ tl / x i Date: ��7//- <br />Revision: 2 1 friday, September 12, 2014 <br />