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BACKWATER PREVENTION DEVICE FINAL <br />41k7r INSTALLATION CHECKLIST <br />Amr, can ,; q+i G r+ '.., ;de S� � L LC <br />Installation Company Name and Contact Info:jj .0 ALl 2a`)& C S�j� �' fall <br />Date Backwater Prevention device (BWD) was installed: ?�)?�/I S Date this form was completed:8— <br />Installation Propen <br />Property Address: <br />Pre -Installation Inspection Checklist: <br />All items must be chocked 'Yes' in order for a BWD to be considered for installation <br />Is the. abasement or level of the house that is at or near assumed sewer main elevation? Z Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? ® Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? RYes ❑ No <br />Site Inspection Checklist: <br />All items must be checked ':'es' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? M Yes El No Condition: Good <br />Does side sewer have at least 1%slope from the building to sewer main? ® Yes ❑ No Describe: _ <br />Have all building sewer drain connections to the side sewer been icentified a/nd located? PYes ❑ 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? P Yes []No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): (a' •�� <br />Where was the device installed (general description, attach map)? 5_oEa <br />Was there any other sewer or storm drainage work completed with the BWD work? Is so please describe. _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? 46�1es ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%7 Tes ❑ No Comments: _ <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? P%fes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? Xl'es ❑ No <br />e (, pA ) 9 ( g <br />Circle the BWD cover�irngatio cov, r�n�sca area 1 traffic load bearing cover drive surface) !access hatch (building) <br />Was property owner <br />Property Owner's <br />Installer's Signature: <br />of ►l�eliktalledAVD? F,!�-Ws ❑ No Comments: <br />Date. <br />Date: <br />Revision: 2 1 Friday, September 12, 2014 <br />