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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Into: taD P CLDI , , <br />Dale Backwater Prevention device (BWD) was installed: 5144 r ' Date this form was�com—p`I'ete=d�:— r 4 <br />Ihstallation'Properly:Owner Naine,and Cit taclarifo E Iyne r a v, P&i r r Lt 0.. JD(lvts {rj h <br />!ProperlYAddreOct ks_ �a q,r1 <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? es ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes ❑� N ' <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? LJ Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered co plete <br />Was side sewer TV inspected from building to sewer main? Yes ❑ No Co dition: <br />Does side sewer have at least 1% slope from the building to sewer main? es ❑ D <br />Have all building sower drain connections to the side sewer been identified and located? <br />to gescribe: <br />Have all property storm drainage connections to the side sewer been identified and located? Yes ❑ f <br />Has property been evaluated for drainage deficiencies with findings communicated to properly owner? [?Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, elc.):C/K; <br />Where was the device installed (general description, attach map)? <br />Was there any other sewer or storm drainage work completed in conjunction with tho BWD work? Is so please describe &J7 <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? j Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope reyuirumont of >1%? E-1 Yes ❑ No Co mentsr___ <br />Can BWD be pulled out for inspection and maintenance after loosening �Ihumb srre [Yes ❑ No <br />Is BWD locked into the proper position and thumb screw lightened? IJ Yes No <br />Circle the BWD cover: irrigaliQ�cgr l f Cds(Oape a44.1 traffic load gegf ig cover (drive surface)! access hatch (building) <br />Was property ownei shown the location of the installed BWD? j_ Yes ❑ No Comments: <br />lProperty0ivnersSighalure.jQ_�:cf-��_ <br />Installer's Signature:._ —�— <br />i2�� 1g'�h Dale: <br />Revision: 2 <br />Monday, September 15, 2014 <br />