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BACKW�4TER PRE1, ;NTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contacl In(o:�Y11P.ri «fJ� '�u'n� �!ryv •�r� t <br />Date Backwater Prevention device (BWD) was inslalled: 1 l ' � Date this form was <br />Inslallation Properiy Owner Name and Contact In(o: �.V'0. (� U�� <br />Properly Address: ' �-• <br />Pre-Installation Inspeclion Checklist: <br />A!! items must be checked 'Yes' in order for a BWD to 6e considered /or instaNation <br />Is there a basement or level of the house that is at or near assumed sewei main elevation?.�c Yes ❑ No <br />Are there fztures in the house lo�ated below the upstream sevrer manhole rim eievation? j5�c Yes ❑ No <br />Is Ihe side sewer currently UNPROTECTED from sewer backups (does not have a BWO inslalled}? {�'YPs ❑ No <br />Site Inspeotion Checklist: <br />All item� must 6e checked 'Yes' 6efore inspectinn is considered complete r� <br />lNas side sewer TV inspected from building to se�ver main? � Yes ❑ No Condilion: 1—�i �.•� <br />Does side sewer have at least 1% slope (rom the building lo sewer main? � Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and localed? �Yes ❑ No <br />ti�ve all property slorm drainage connections to the side sewer been identified and located? (�Yes ❑ No <br />Has property been evaluated tor drainage defciencies with findings communic2ted lo property owner? � Yes ❑ No <br />Installation Details: � � <br />What type and brend of RWD was installed at this site (Clean Check BWV, Grinder pump, etc.):�P/'�rY'S"�,fl � <br />Where was Ihe device inslalled (general description, aftach map)? �� �' r. �'Cu �o� �S -���{- <br />Was there any other sewer or storm drainage work completed in �onjunction with the 6WD work? Is so please describe: _ <br />Installation Checklist: <br />Are a�l downspouts and site drainage disconnected from upsiream o( the BW�? �'Yes ❑ No Comments: <br />Does DWD posiiioning meets minimum slope requirement of >140? �Yes ❑ No Commenls: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? �Yes ❑ No <br />Is BWD locked into the proper posiiion and lhumb screw tightened? � Yes ❑ No <br />Circle lhe BWD cover rigation cover (I ndscape area) I Iraffic load bearing cover (drive suriace)/ access hatch (bullning) <br />Was property owner shown Ihe location of the inslalled BWD? � Yes ❑ No Comments: <br />Property Owner's Signature: _ Date: <br />Installer's Signature: Dat�: i �� �`T <br />I <br />Revision: 2 1 friday, September 12, 2014 <br />