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i'S'AC WATER PREVENT ON DEVICE FINAL <br />INS.TALLATON CHECKLIST <br />A I'ni n Ce'VI '5C'P <br />Installation Company Name and Contact <br />Date Backwater Prevention device (BWD) was installed: Date this form was com/,ipleted: LS- <br />Installation Property Owner Name and Contact Info: (24a5�rj11 llrj.'`1.r7��-+S��Z <br />Property Address: <br />Pro -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BWD to be considered for installation <br />Is there a basement or level of the house that is at or r-ar assumed sewer main elevation? [� Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? P 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 /v <br />Was side sewer TV inspected from building to sewer main? Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? F Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? ['Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? jgYes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to properly owner? }Yes ❑ No <br />Installation Details: What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): _6c-4 <br />N <br />4' i X�G <br />Where was the device installed (general description, attach map)? _fsi GYe <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 BIND? [WYes El No Comments: <br />Does BWD positioning meets minimum slope requirement of>1%7 9 Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? Wes ❑ No <br />Is BIND locked into the roper position and thumbscrew tightened? W Yes U No <br />Circle the BWD co er: irrigation cover, (!landscape area) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown t e localion of the installed BWD? "Yes []No Comments: <br />Property Owner's Signature:4 ✓ Date: (7� 7 <br />Installers Signature: r4- Dale: <br />Revision: 2 r7X 1 Friday, September 12, 2014 <br />i <br />