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r <br />BACKWATER PREVENTION DEVICE FINAL <br />E� INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) was installed: 2�/ 3 Date this form was completed: <br />Installation Property Owner Name and Contact Info: �qA 1 t S o )1 <br />Property Address: l �Cfl (&'i vt i e r A ve, ey e ]6� i,% 9;�W 20 1 <br />Pre-histallation 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 of near assumed sewer main elevation? SaYes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? L21re-s ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BIND installed)? [R 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? [E Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? Ries ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? H"Yes []No <br />Have all property storm drainage connections to the side sewer been identified and located? Z"YY'es []No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? eyes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): Clean e1"4 afk <br />Where was the device installed (general description, attach map)? hack �a r �l - u E cow rev o f- c-f etk <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? is so please describe: VO <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? Ryes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? a Yes ❑ No Comments: _ <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? [ryes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? 'Vyes ❑ No <br />Circle the BWD cover: irr <br />Was property owner shown <br />Property.Owner s 3ignature. <br />Installer's Signature: <br />Revision: 2 <br />ndscape area) f traffic load bearing cover (drive surface) I access hatch (building) <br />ri 'the installed BWD? &Y/es ❑ No Comments: <br />Date: 3 3 r <br />Monday, September 15, 2014 <br />