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BACKWATER PREVENTION DEVICE FINAL <br />4M7r INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) was installed: <br />Installation Property Owner Name and Contact Info: �I <br />Property Address: 7,2- if <br />Date this form was completed: 25 � /�' <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? 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)?Yes ❑ No <br />Site,Inspection Checklist: TTTTTT <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? nes ❑ No Condition: <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 identi6e and located? Yes ❑ No <br />ZZ <br />Have all property storm drainage connections to the side sewer been identified and located? AYes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? Efyes ❑ No <br />Installation Details: <br />What type and brand of BIND was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? E 5 J <br />Was there any other sewer or storm <br />Installation Checklist: <br />in conjunction with the BWD work? Is so please describe: _ <br />Are all downspouts and site drainage disconnected from upstream of the BWD? Yes ❑ No Comments: <br />Does BIND positioning meets minimum slope requirement of >1%?/ Yes F1 No Comments: <br />Can BWD be pulled of for inspection and maintenance after loosening thumb screw? (Yes El No <br />Is BWD locked into the proper position and thumb screw tightened? Vyes ❑ No/ <br />Circle the BWD cover: irrigation cover (landscape area) I traffic load <br />Was property owner shown the location of the installed BJV(�2-0 <br />Property Owner's <br />Installer's Signature: <br />Revision: 2 <br />cover (drive surface) / access hatch (building) <br />Yes ❑ No Comments <br />Date: ]E �y /. <br />Date: v Z-n <br />Friday, September 12, 2014 <br />