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0$�BACKWATER PREVENTION DEVICE FINAL <br />ff INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: /9i`F Pr/vM ,b rnz to e- 117- f =,4/ 92-o!Z 3 <br />Dale Backwater Prevention device (BWD) was installed: i�-/�i — Date this form was completed <br />L9-L�-Ztr7 5 <br />Installation Property Owner Name and Contact Info: �i�-f �J — Sr2 - %YrZ <br />Property Address: �3S-7 Z 12c&leA- , — —� <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? Pies ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [g'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? es ❑ No Condition: 17I2/ c_rw�- C�c�•-i`e .dot <br />Does side sewer have at least 1% slope from the building to sewer main? � ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? KFYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? ,Yes ❑ No <br />Has properly been evaluated for drainage deficiencies with findings communicated to property owner? 5g-Yn [:]No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description attach map)? 41dZ tea 01_ I'1 %a u <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />All. o — <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? es ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? ©-Y6s­ ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? EJ�Yes []No <br />Is BWD looked into the proper position and thumb screw tightened? ❑ems ❑ No <br />Circle the BWD cover: irrigalio ver (landscape a ) / traffic load bearing rover (drive surface) / access hatch (building) <br />Was property owner shown the location of the installed BWD? es ❑ No Comments: <br />Property Owner's Signature: & Date: 41-1 `!— 7-15 <br />Installer's Signature: Date: <br />Revision: 2 1 Friday, September 12, 2014 <br />