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� �� BACKWATER PREVEPITION DEVICE FINAL INSTI�L.LATION CHECKLIST Installation Company Name and Contact Info: _ i��-o Q(a.rw.�3� Nlo L(. � Date Backwater Prevention device (BWD) �vas installed: 1- l j� - i� Dale this form was completed: i- 20 - t r Installation Properiy Owner Name and Contad Info: PropertyAddress: ESTES r►�rcNaeL 7� l�rrvrt M 30u2 lCv+" EVCTZc-9C'[' W� Pre-Installation Inspection Checklist: Alf items must 6e checked 'Yes' in order for a BWD to 6e considered for insfallation Is there a basement or level of the house ihal is al or near assumed sewer main elevation? [�es ❑ No Are there fixtures in the house localed belmv lhe upstream sewer manhole rim elevation?-�Yes ❑ No Is the side sewer currently UIJPROTECTED from se�ver backups (does not have a BWD installed)? (�Yes ❑ No Site Inspectic�� Checklist: All ifems must be checked 'Yas' be(o�e inspection is considered compfete Was side sewer N inspected irom building to sewer main? �Yes ❑ No Condition: N E �`-' Does side sewer have at �east 1% slope from the huilding to sewer main? '�Yes ❑ No Describe: Have all building setver drain connections to the side se�ver been identified and located? [�,Yes ❑ No Have all property storm drainage conneclions lo the side sewer been identifieu and localed? � Yes ❑ No Has property been evaluated for drainage deficiencies with findings communicated to propedy owner? � Yes ❑ IJo Installation Details: What rype and brand of BWD v�as installed at this site (Clean Check BWV, Grinder pump, etc.): C(xrou �(�{ �cl� V1'here vaas the device installed (general description, attac� Was there any other sewer or storm drainage work completed in conjunction with the BWD �vork? Is so please describe: _ s't�n�� LI►-�cr 7LuAC.t�+CL1� d Installation Checklist: Are all c�ownspouls and sile drainage disconnected fmm upsiream of the BWD? �Yes ❑ No Comments: Does B4ND posi�ioning mecls minimum slope requirement of >1%'t �Yes ❑ No Comments: Can BVVD be pulled out (or inspection and maintenance a(ter loosening lhumb screw? Q�Yes ❑ No Is BWD Jocked into lhe proper posilion and ihumb s�rew tightened? � Yes ❑ No Circle the BWD cover: irtigation cover (landscape area) I traf(ic load bearing cover (drive sudace)1 access hatch (huilding) Was properly owner shown the localion o( th inslalled BWD? Yes ❑ No Commenls: i Property Owners Signatur . % Dale: _ �� / /�' �� Installer's Signature: Date: /— 2 v—/� Revision: 2 1 Tuesday, September 16, 2014