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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) was installed: U— 2 ? _ � 5 <br />Installation Property Owner Name and Contact'nfo: _ <br />Property Address: -� . Z —0(-tV. <br />Prednstallation Inspection Checklist: <br />=UP9-U <br />this form was completed: Lr'=Z�! /- S <br />All items must be checked 'Yes' in order for a BWV to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? Ples ❑ No <br />Are there fixtures in the house located below the upstedm sewer manhole rim elevation? es ❑ No <br />Is the side sewer currently UNPROTECTED fmm sewer backups (does not have a BWD installed)? rt,}�s ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes'before inspection is considered complete USG. <br />Was side sewer TV inspected from building to sewer main? m,Ws- ❑ No Condition: l/ <br />Does side sewer have at least 1% slope from the building to sewer main? [ems ❑ No Descnhe: <br />Have all building sewer drain connections to the side sewer been identified and located? 9`11s- ❑ No <br />Have all property stone drainage connections to the side sewer been identified and located? Deg ❑ No NO <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [(Ales ❑ No <br />Installation Details: <br />What type and brand of BWD was, installed at this sits (Clean Check BWV, Grinder pump, etc.): ( a C cL <br />Where was the device installed (genera! description, attach map)? /!% 14, <br />Was there any other sewer or storm drainage work completyJ in "unction with the BWD work? Is so please describe: <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? es ❑ No Comments: <br />Does BWD positioning meals minimum slope requirement of >1010? s ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? r[ YM ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? 53AW ❑ No <br />Circle the BWD cover: irrigation cover (landscape area) Mc load bearing cove surface) / access hatch (budd,ng) <br />Was property owner shown the location of the installed BWD? [ es No Comments: <br />Property Owner's Signa v� Date: 5- <br />Installer's Sgnatu Date: <br />4q-cl <br />Revision: 2 1 Friday, September 12, 2014 <br />