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BACKWATER PREVENTION DEVICE FINAL <br />ter. INSTALLATION CHECKLIST <br />Installation Company Name and Contact Into: <br />Dale Backwater Prevention device (BWD) was installed: <br />pavto\ Seit p[Z /�06 1-/6S -y/93 <br />Date this form was completed: (1/` / 3 <br />Installation Property Owner Name and Contact Info: V&\JIAV 5 ho Icrez� <br />Property Address: 1%2� l tt�t Ad, <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BV✓D to be considered for installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? 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 'Yes' before inspection is consideredomplete <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? Yes ❑ t <br />Have all building sewer drain connections to the side sewer been identified and located? <br />o Describe: _ <br />[Ye El No <br />Have all property storm drainage connections to the side sewer been identified and located? Yes ❑1No <br />Has properly been evaluated for drainage deficiencies with findings communicated to property owner? [lJ Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this <br />Where was the device installed (general descriplic <br />Was there any other sewer or slorp 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? yes [I No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Oyes []NO CQmments: <br />Can BWD be pulled out for inspection and maintenance after loosening gtth%mb screw? O Yes ❑ No <br />Is BWD locked into the proper position r 'thy[�rtrscre tightened? Yes ❑ No <br />Circle the BWD cover: irrigation cov r (landsca ueaj�traf tic load earing cover (drive surface) I r cceas hatch (building) <br />Was property owner shown the location o the installed BWD? Yes ❑ No Comments: <br />Property Owner's Signat r : Cat )i c Dale: 22 f <br />Installer's Signature: Dale: . <br />Revision: 2 1 Friday, September 12, 1014 <br />