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BACKWATER PREVENTION DEVICE FINAL <br />�F INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: ilew <br />Date Backwater Prevention device (BWD) was installed: 3 fzDn5 JJ Date this form was completed: Z <br />Installation Property Ovner Name and Contact Info: Aidnae i (ri�(eyoU i92-52 Z°i L Z Z1,137 <br />Property Address: thE� t0aliltJ St Sdt1,(rAA- tr)A 1AUI <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? ,Yes []No <br />Are there fixtures in the house located below the upstream server manhole rim elevation? Q Yes ❑ No <br />Is the side server currently UNPROTECTED from server backups (does not have a BWD installed)? KYes ❑ No <br />Site Inspection Checklist: <br />All items must be checked'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? MYes ❑ No Condition: <br />Does side server have at least 1% slope from the building to server main? ,Yes ❑ No Describe: <br />Have all building sewer drain connections to the side server been identified and located? jmyez, ❑ f10 <br />Have all property storm drainage connections to the side server been identified and located? 1K Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? 4 Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Cleo heck BWV, Grinder pump, etc.): CSC-LCC-44 ec-K- <br />Where was the device installed (general description, attch map <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 fn.m upstream of the BWD? YN <br />M Yes []No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? VYes ❑ No <br />Is BWD locked into the proper position and thumb screw lightened? (A Yes ❑ No <br />Circle the BWD cover: irrigation cover <br />Was property owner shown the locatk <br />Property Owner's Signature: <br />Installer's Signature:. <br />i traffic load bearing cover (drive surface) I access hatch (building) <br />BWD? R] Yes ❑ No Comments: <br />Date: <br />Dale: <br />Revision: 2 1 Tuesday, September 16, 2014 <br />