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BACKWATER PREVENTION DEVICE FINAL <br />4L INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: H L"1 P� v t " t' 0— <br />Date Backwater Prevention device (BWD) was installed: 5-- 2/ — i.S Date this form was completed: 5---2 3 — I'3— <br />Inslallation Property Owner Name and Contact Into: ' <br />Property Address: ,fir, c.1 12 r Vt' r rr rei ve L v i /'��� <br />�J <br />Pre -Installation Inspection Checklist: <br />All ilems 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? [X Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? [M Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?Oycs ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes'before inspection is considered complete <br />VJ d ewer TV ins ected from building to sewer main? (Z Yes ❑ No Condition' <br />boon— Ott)cor�ckcre <br />ass es e p <br />Does side sewer have at least 1% slope from the building to sewer main? 9Yes []No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? ,Yes []No <br />Have all property stone drainage connections to the side sewer been identified and located? F9 Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? f TYeS ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site Clean ChPdA BWV, rinderpump,etc.): <br />Where was the device installed (general descdptio attach m <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? FlYes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of>1%7 V)Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? M Yes ❑ No <br />Is BWD locked into the to er position and thumb screw lightened? ,J Yes U No <br />Circle the BWD cove : irrigation c landscape area) / traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner showLeellb�cafi'h of the Installed BWD? 0 Yes ❑ No Comments: <br />Property Owner's Signatur <br />/ Dale: <br />3 C S <br />Installer's F.icnahDate: <br />ue• 9 —' <br />Revision: 2 1 Tuesday, September 16, 2014 <br />