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BACKWATER PREVENTION DEVICE FINAL \0 INSTALLATION CHECKLIST Installation Company Name and Contact Into: .,a•r't1 PF FLli'2--LL t ).11 r314(: TW, (. _ Date Backwater Prevention device (BWD) was installed:5�I S // 5 Date this form was completed: S ✓SAS Installation Property Owner Name and Contact Info: vt� H ✓ ire h s� rec d Property Address: / 7o S %J� Ale- L5v zrj� Pre•Installation Inspection Checklist: All items must be checked 'Yesin order for a BWD to be considered for installation Is there abasement or level of .he house that is at or near assumed sewer main elevation? E Yes []No Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes ❑ NNoo Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? tJ gyres [:]No Site Inspection Checklist: All items must be checked 'Yes' before inspection is considered complete Was side sewer TV inspected from building to sewer main? ETYes ❑ N, oo Condition: U . Does side sewer have at least 1% slope from the building to sewer main? Yes ❑ No_ ,Mcribe: Have all building sewer drain conn-etions to the side sewer been identified and located? to Yes ❑ Na .sHave all property storm drainage connections to the side sewer been identified and located? [Yes ❑ No Has property been evaluated for drainage deficiencies with findings communicated to property owner? [] Yes ❑ No Installation Details: What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): Where was the device installed (general description, attach map)? _)�x+c 4 A,6r-4 , Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: ccic7 Installation Checklist: Are all downspouts and site drainage disconnected from upstream of the BWD? 15`Yss' [] No Comments: Does BWD positioning meets minimum slope requirement of >1%? ('J Yes [:]No Can BWD be pulled out for inspection and maintenance after loosening thumb screw? Is BWD locked into the proper position and thumb screw tightened'? [ryes n No Co ments: _ Yes ❑ No Circle the BWD cover: i hi c�Over (landscape area) / traffic load bearing cover (drive surface) f access hatch (building) Was prop any owner shown the location of the installed BWD? Yes ❑ No Comments: Property Owner's Signature: r �� -r Dale: ( Installer's Signature:- Dale: SZ5 2els Revision: 2 1 Monday, September 15, 2014