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BACKWATER PREVENTION DEVICE FINAL <br />00� <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) was installed: 3-f '1G• 5' Date !his form was completed:' <br />Installation Property Owner Name acid Contact Info: j �c� vl 2 Sag ` 13� <br />Property Address: q�\)4 - . �J��� <br />Pro -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation <br />Is there n basement or level of the house that is at or near assumed sewer main elevation? W. Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? 0 Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? WI Yes ❑ No <br />Site Inspection Checklist: <br />q3 <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? RE Yes ❑ No Condition: — <br />Does side sewer have at least 1% slope from the building to sewer main? QM Yes ❑ No Describe: l`:cx•U od <br />Have all building sewer drain connections to the side sewer been identified and located? 10 Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? w Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? IO Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site Clean Chec BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? �%U� 4 Lj <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: 00 <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BIND? IN Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? JjYes [--]No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? I$ Yes ❑ No <br />Is BWD locked into the proper posrion and thumbscrew tightened? Eyes []No <br />Circle the SWO cover: irrigation cov (landscape area) traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of the installed BWD? Q Yes ❑ No Comments: f' <br />Property Owner's Signature: Date: <br />Installer's signature: � btu �i�� Date: a3' 16K <br />Revision: 2 1 Monday, September 15, 2014 <br />