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BACKWATER PREVENTION DEVICE FINAL 411-7r INSTALLATION CHECKLIST Installation Company Name and Contact Into: Date Backwater Prevention devire (BWD) was Installed: 5-- P — I L Date this form was completed: S— -lT Installation Property Owner Name and Contact Info: xv ; {,cn + Property Address: r i I ct-i to S`t Pre -Installation Inspection Checklist: All items must be checked'Yes' in order for a BVrD to be considered for installation Is there a basement or level of the house that is at or near assumed sewer main elevation? 2 Yes ❑ No Are there fixtures in the house located below the upstream sewer manhole rim elevation? n Yes ❑ No Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? 0 Yes ❑ No Site Inspection Checklist: M items must be checked Yes' before inspection is considered complete Was side sewer TV in,pected from building to sewer main? 4 Yes ❑ No Condition: Does side sewer have at least 1% slope from the building to sewer main? Yes 0 No Describe: Have all building sewer drain connections to the side sewer been Identified and located? Yes ❑ No Have all property storm drainage connections to the side sewer been Identified and located P Yes ❑ No Has property been evaluated for drainage deficiencies with findings communicated to property owner? P Yes []No Installation Details: What type and brand of BWD was installed at this si e (Clean Check B� rinder pump, etc.): Where was the device installed (general description, a ach�rrapp7 J, cwl Si 4 Was there any other sewer or storm drainage work completed in conjunction with the MID work? is so please describe: _ Installation Checklist: Are all downspouts and site drainage disconnected from upstream of the BWD? 0 Yes ❑ No Comments: Does BWD positioning meets minimum slope requirement of >1%? V] Yes ❑ No Comments: Can BWD be pulled out for inspection and maintenance after loosening thumb screw? 14 Yes ❑ No Is BWD locked into the pro er osition and thumb s r w tightened? �] Yes ❑ No Circle the BWD cove .irrigation cover (landscape a" a)1 affic load bearing cover (drive surface) I access hatch (building) Was properly owner shown the location of the ins a e BWD7 /� Yes ❑ No Comments: Property Owner's Signature: Installers Signature: Date: Date: S — - r S Revision: 2 1 Friday, September 12, 2014