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04LBACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Irdo: �0!o//d 3 5r7 / 'c:27 <br />Date Backwater Prevention device (BWD) was installed: Date this form was completed: Z-- �3 As - <br />Installation Property Owner Name and Contact Info: 77eY Yr�. r/ 3�15 5339 <br />Property Address: 7707 /Z,--ckg F P//Pr — <br />Pre installation Inspection Checklist: <br />All items must be checked'Yes'in order fora 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? P Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? FD Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?A 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? P Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? P. Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? J] 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 property owner? Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this s" lean Check BWV; rinder pump, etc.): <br />Where was the device Installed (general description, attach map)? I���t.,.,iJ,.o <br />Iiye wcrY <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? JaYes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? El Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? , Yes ❑ No <br />Is BWD locked into the progeLposi4oaaad4Wmb-screw, ightened? QJ Yes ❑ No <br />Circle the BWD c r: imigauor <br />Was property owner shown the <br />Property Owner's Signatur <br />Installer's Signaturo <br />Revision: 2 <br />traffic load bearing cover (drive surface) / access hatch (building) <br />of the Installed BWD? �0Yes []No Comments: <br />Date: 2 /! l/r� <br />Date: Z/f <br />Friday, September 12, 2014 <br />