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04;L BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />ffk-r-I can ia-ifi e <br />Installation Company Name and Contact Info` <br />�L <br />Date Backwater Prevention device (BWD) was inslalled: jam_ Date this form was completed: D <br />Installation Property Owner Name and Contact <br />sac - -4�, <br />Property Address: C ( gkx./j r[ l� T <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BVID to be considered for installation <br />Is there abasement or level of the house that is at or near assumed Sevier main elevation? (Yes []No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? UYes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? L es No <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? RYes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? <br />es ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? 19Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identifed and located? ( + es 0 No <br />Has property been evaluated for drainage deficiencies with findings communicated to property oti((rner? Ps ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BLVV, Grinder pump, etc.)li�c <br />Where was the device installed (general description, attach map)? Sy.) �l r y�L��� <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD tvork? Is so please describe: <br />n / 'in // — <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? PYos ❑ No Comments - <br />DOE —IS BWD positioning meets minimum slope requimment of >1%? (Yes []No Comments:. <br />Can B'WD be pulled out for inspection and maintenance after loosenin/g Thumb screw? j]v Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? RYes ❑ No <br />Circle the BWD cove . irrigation cover W)dscape area) I traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown a location of the installed BWD? , Yes F, No Comments: <br />Property Owners <br />Installer's Signatui <br />Revision: 2• <br />Date: /°',/1.5' / f \ <br />Date: _I QW1'S— <br />rnuay, September 12, 2024 <br />