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BACKWATER PREVENTION DEVICE FINAL <br />064L INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: <br />Dale Backwater Prevention device (BWD) was installed:_ Date this form was completed: 2" <br />Installation Property Owner Name and Contact Info: Vta t,-E !L► F (-I _ <br />Property Address: 1-1 Oct IiC=�7_LAA _!l_R7 n_I <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BWD lobe c,)nsidered for installation <br />Is there abasement or level of the house that Is of or near assumed sewer main elevation? g es ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? mfr.'s ❑ 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? ii� ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? es ❑ No Describe: _ <br />Have all building sewer drain connections to the side sewer been identified and located? es No <br />Have all property storm drainage connections to the side sewer been identified and located? Etlles ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? es ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? tM1l410 <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />�v>`F <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? es ❑ No Com ts: <br />Can BWD be pulled out for inspection and maintenance after loosening Ihum� screw? es ❑ No <br />Is BWD locked into the proper ositiQaj1uJJhuMb screw tightened? Pfas ❑ No <br />Circle the BWD cover irrigation cover (landscape area , traffic loaLLd, <br />Was property owner shown the location of the installed BWD? }� <br />Property Owner's Signature: <br />Inslaller's Signature: <br />cover (drive surface) f access hatch (building) <br />❑ No Comments: <br />Date: UZ �� -- <br />Date: I-L in 11y <br />Revision: 2 1 Monday, September 15, 2014 <br />