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OOLBACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: APe/% i %. /7 / z s e/l/2s ) 3;�57 — /S � 7 <br />Date Backwater Prevention device (BWD) was installed: lliZl / Date this form was completed: 1101 <br />Installation Property Owner Name and Contact Info: G!, e ,-Y/ ,� .• /ems Tc/Z 5) 5 2 — SsS�z <br />Property Address: 7Z Ave- /vim Z ve—,- 0� <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? 2yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? -eyes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? L31es ❑ 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 ❑ N,-o, Condition: <br />Does side sevrer have at least 1% slope from the building to sewer main? � res ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? 2es ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? tes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? OYes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site an Check B prinder pump, etc.): <br />Where was the device installed (general description, altac 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 from upstream of the BWD? PTYes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Z'YeS ❑ No Comments: <br />Can BVVD be pulled out for inspection and maintenance after loosening thumb screw? IrYes ❑ No <br />Is BWD locked into the proper position im screw tightened? ❑ Yes ❑ No <br />Circle the BWD cover: ' ngation cover an scape ar c load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installe BWD? [ryes ❑ No Comments: <br />Property Owner's Signatur • Date: t �� <br />Installer's Signal Date: J/ 9// f <br />Revision: 2 1 Monday, September 15, 2014 <br />