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BACKWATER PREVENTION DEVICE FINAL <br />OL INSTALLATION CHECKLIST <br />Installation Compeny Name and Contact Info: <br />Dale Backwate, Prevention device (B'WD) was <br />Installation Pruperty Owner Name and Contact Info: I <br />Property Address: 1 1) �'�7T' ` SY <br />Date this form was completed: <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BV'JD to be considered for inststlation <br />Is there abasement or level of the house that Is at or near assumed sewer main elevation? ❑ Yes []No <br />Are there fudures in the house located below the upstream sewer manhole rim elevation? ❑ Yes El No <br />is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? ❑ Yes ❑ No <br />Site inspocfion Checklist: <br />All items must be checked Yes' before inspection Is considered complete <br />Was side sewer TV inspected from building to sewer main? " ❑ No Condition: It'i <br />Does side sewer have at least 1% slope from the building to sewer main? ©-N�s ❑ No Descdbe: <br />Have all building severer drain connections to the side sewer been identified and fixated? ©i es ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? B Yes []No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? QYes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): l <br />Where was the device Installed (general description, attach map)? <br />Was there any other sewer or storm drainage wprk completed in conjunction with the BWD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD?. es ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%7 fires ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb s rew? es ❑ No <br />Is BWD locked Into the proper position and thumb screw tightened? es ❑ No <br />Circe the BWD co,.,. Irrigation cover (landscape ama) batfit load bearing cover drive surface) f access hatch (building) <br />Was property owner shown the locatio a stal ❑A'6 ❑ No Comments: <br />Property Owner's Signatu :, ate: )�-00—I ' <br />Installer's Signature: U 9 Date: 'us� <br />R,Mslon: 2 1 Friday, September 12, 2014 <br />