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BACKWATER PREVENTION DEVICE FINAL <br />4wrr INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: J r i'e L - < < - `1,f7 1 U• r <br />Date Backwater Prevention device (BWD) was installed: 1-/ 21-1 Uatt this form was completed: <br />Installation Property Owner Name and Contact Info: •%mil/XI/� � � 2 �YO <br />Property Address. <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be c )• :.dered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? 014-es ❑ No <br />Are there fixtures In the house located below the upstream sewer manhole rim elevalion? M-y6s ❑ No <br />Is the side sewer currc ntly UNPROTECTED from sewer backups (does not have a BWD installed)? [•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? [ ],Yes ❑ No Condition: It xJ2 C e-%a,ez-' <br />Does side sewer have at least 1% slope from the building to sewer main? [Z>6 ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? Z es ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? [Iyoa- ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? L.Yes ❑ No <br />installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc) c-CLc I-P <br />Where was the device installed (general description, attach map)? � c �� 2 <br />Was there any other sewer or storm drainage wRrac completed in conjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: �, ✓ bu W �_ <br />Are all downspouts and site drainage disconnected from upstream of the BWD? El Yes [1]416 Comments J t <br />Does BWD positioning meets minimum slope requirement of > 1%? 51-y ❑ No Comments: — <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? EjUs ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? ❑ No <br />Circle the BWD cover. iidgation cover (landscape area affic load bearing cover ive surface) / access hatch (building) <br />Was property owner shown the location of the installed BIND? DYer- ❑ No Comments:: <br />Property Owner's SignatureI Date. I I I <br />Installer's Signature: Date: h% �r <br />Revision: 2 1 Friday, September 12, 2014 <br />