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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST 114612/1 <br /> Installation Company Name and Contact Info: 5o, 6,,,,,fir,? 1 4?-5-?� -7S 71( <br /> Date Backwater Prevention device(BWD)was installed: q/acI/ f Date this form was completed: <br /> Installation Property Owner Name and Contact Info: iaa <br /> Property Address: ,j 1?3 (4000a(A.,: „ Ave__ , FA) -t <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 a basement 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? ?❑y 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 considered complete <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? -"Er Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? . Yes ❑ 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? ©'Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump, etc.): C Vt , `IkzV <br /> Where was the device installed (general description, attach map)? a` �ro r s s��� �,�� �� �•o� <br /> Was there(any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br /> 1` �'y�J�0.@2 G. —1 " ' i Gt_ 5�'Q iJG e- IO C'vl\ry Prt p+'1 C. "41 4"\6i.CN\c?,.J WI,("Ns\ a r \I 'J aaSc� <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? 2 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? ©Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? 51 Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area /traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? hf Yes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature' —Th Date: \ <br /> Revision: 2 1 Friday,September 12, 2014 <br />