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• <br /> BACKWATER PREVENTION DEVICE FINAL <br /> lelP/As/r:cal�- INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: /3l irvi br'/L-- lLC -42 r-•4 B' 2.3 <br /> Date Backwater Prevention device(BWD)was installed: /1-1D q 441 ate this form was completed: // /D /6 <br /> Installation Property Owner Name and Contact Info: 772-r11.,V <br /> (J¼Qi ,I1 <br /> Property Address: / 711 tu'i, / v-• ^ <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? Ugh Ug-YR f No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? L[ Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? 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? ❑ No Condition: jb �S rri <br /> Does side sewer have at least 1%slope from the building to sewer main? es ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Rfis El No <br /> Have all property storm drainage connections to the side sewer been identified and located? [ . El No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? des [1 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check B ,Grinder pump,etc.): C . <br /> (generalp ach map)? tttt " 6 r4at'rL. J <br /> Where was the device installed d cri tion, l../ <br /> Wa ere any other sewer or st drainage wor completed in conjun on with th9 BWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? [0-fer0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? raYess El No <br /> Is BWD locked into the proper position and thumb 'reww tightened? PM ❑No <br /> Circle the BWD cover i ation cover(lands a ' y-?traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? Esr ❑No Comments: <br /> Prope&t -Owner's,,Sig._ .._ Date: //—/f . go <br /> /L./ <br /> Installer's Signatur . Date: //-/C_- a/L/ <br /> Revision:2 1 Friday,September 12,2014 <br />