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BACKWATER PR�VENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Date Backwater Prevention device (BWD) �vas installed <br />Installation Property Ovmer Name and Contact Info: <br />Property Address: <br />this form was <br />2 <br />Pre•Installation Inspection Checklisf: <br />All items must be checked 'Yes' in order (or a BWD fo be considered for installation <br />Is there a basement or ievel of the house that is al or near assumed sewer main elevation? [�NE� 0 No <br />Are there fixtures in the house located below Ihe upstream sewer manhole rim elevalion? es ❑ No <br />Is the side sewer currenlly UNPROTECTED from sewer backups (does not have a BWD inslalled)7 [� YeS� ❑ No <br />Site Inspection Checklist: <br />Alf items must 6e checked 'Yes' be%re inspection is considered complete � t <br />Was side sewer TV inspected irom building lo sewer main7 [L}Y@s � No Condition: �� <br />Does side setiver have at least 1% slope from the building to sewe: r�ain? [�]�es' � No Cescribe: <br />Have all building sewer drain connections to the side sewer been identified and located? es ❑ No <br />Have all property storm drainage conneclions to the side sewer been identified and Iocated? �1'es ❑ No <br />Has property been evaluated for drainage deficiencies v�ith findings communicated to property o�vner? QXes� 0 No <br />Inshll�tion Details: % <br />What rype and brand of BWD was installed at Ihis site Clean GheeE' WV, G�rinder pump, etc.): <br />Where �vas the device installed (general description, attach map)? T� �' �'+--�� <br />Was there any other sewer or stortn drainage work comp�t�d in conjunction with the BWD work? Is so please describe: _ <br />� <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from ups�ream of lhe BWD7 [�}Y s�L] No Comments: <br />Does BWD positioning meets minimum slope requirement ol >190? es ❑ No Comments: <br />Can BWD be pulled out (or inspection and mainlenance afler loosening ihumb scre��+1 [�] Ye�� No <br />Is BWD locked into the proper position and lhumb scre�v lightened? [!�-Y�f� No <br />Circle the BWD cover: irrigation cover (landsc be area) ! traKc load bearing cover (drive suriace)1 accdss hatch (building) <br />Was property owner shown the localion�of�in�lled BWD7 � YeSr[] No Comments: <br />Properly Owner's <br />Installer's <br />Date: ���� o �� �i' <br />Date: `�'"'%O '—` �l - <br />� <br />Revision: 2 1 Friday, Septem6er 12, 2014 <br />