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BACKWATER PREVENTION DEVICE FINAL <br />�.- INSTALLATION CHECKLIST <br />Installation Company flame and Contact Info: &aella Aa <br />J <br />Date Backwater Prevention device (BWD) was installed Date this form was completed: <br />Installation Property Owner Name and Contact Info: ,7otek /� fh ,2ot1c <br />Property Address: 3c/16 %z,,-c%eire,iPr <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation <br />Is ihere abasement or level of the house that is at or near assumed sever main elevation? (Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhuie rim elevation? 0] Yes ❑ No <br />Is the side server currently UNPROTECTED from sewer backups (does not have a BWD installed)?,Z Yes ❑ 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? n'Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sseew_er main? ❑Kes []No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? Q Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? 'Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to properly owner? ,0 Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed al this site lean Chec t ,Grinder pump, etc.): <br />Where was the device installed (general description, attach map . 34, G �D 1,4 loss a <br />Was there any other sewer or storm drainage work completed in conjunction with the VVD work? Is so please describe: -- <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? ZYes ❑ No Comments: <br />Does BVdD positioning meets minimum slope requirement of>1%? P Yes ❑ No <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? <br />Comments: <br />❑ Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? [/] Yes ❑ No <br />Circle the BWD co . irngation cover land 'i traffic load bearing cover (drive surface) i access hatch (building) <br />Was property owner shown the location of the installed BWD? OYes []No Comments: <br />Property Owner's <br />Installers <br />Revision: 2 <br />Date: <br />Date: <br />Monday, September 15, 2014 <br />