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BACKWATER PREVENTIC3IN DEVICE FINAL <br />4Ell=6NSTALLA i"If! CHECKLIST <br />li�►'lEri ccxn ��;� � � � s �dr? Sc.�tz�r � i_c <br />Installation Company Name and Contact Infol5r, (� ` R;) `�d� -L 5j� n i I -f 4, b=N I') -4an <br />Date Backwater Prevention device (BWD) was installed: 3��_ Date this form was completed: 3 <br />Installation Property owner Name and Contact Info: &' s Q Fir f Y1 320 ',�Qt • �n I <br />Property Address: <br />Pre -installation Inspection Checklist: <br />All items must be checked'Yes' in order for a BWD to be considered for installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? I� Yes []No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation?F Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [�Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked Tes' before inspection is considered complMe <br />Was side sewer TV inspected from building to sewer main? � Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? Pa7yes ❑ No Describe: <br />Have all building sewer drain connectior..s to the side sewer been identified and located? [ayes []No <br />Have all property storm drainage connections to the side sewer been identified and located? X"Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? SR'Yes ❑ No <br />Installation Details: n <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): & -zv <br />Where was the device installed (general description, attach map)? _ _ P a.(iQ_ ngi- <br />Was there any other sewer or storm drainage work completed in 5onjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? NYes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1 %? 0Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after to^sening thumb screw? flaxes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? Wes ❑ No <br />Circle the BWD cov(: irrigation cover ldscape area) / traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of the installed BWD? Palyes ❑ No Comments: / <br />Property Owner's Signature: id {.t ' � J Datr: 24 10 1 <br />Installer's Signature: Date: <br />Revision: 2 1 Friday, September 12, 2014 <br />