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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: J[nD � bps d Kck�1�� <br />Date Backwater Prevention device (BWD) was installed: iO/Z/�,0/5 Date this form was completed: 16)&IJO15 <br />Installation Property Owner Name and Contact Info: /11 T tl itl doh I �a�a IJ q o� Z�61//djl <br />Property Address ZI I I Z ls� 5F r x.r f (-y ttgrrbl V <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BWD to be considered for installation I <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? L Yes ❑ No i <br />i <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? y Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?Yes ❑ 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? L�z Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? 123es ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? IFYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? Ryes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? Yes ❑ No <br />Installation Details: <br />1. <br />What `ype and brand of BWD was installed at this site (Clean Check BWV, GI rinser pump, etc.): C t etu^ c1cc <br />Where was the device i stalled (general description, attach map)? <br />�10acSin rt, n <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? J0Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1 %? tYes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? OYes ❑ No <br />Is 6WD locked into the proper bland- screw tightened? S Yes ❑ No <br />Circle the BWD cover ' igation cover (landscape are traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown re oca ion o the installed BWD7 c&Yes ❑ No Comments: <br />Property Owner's Signature: Date: <br />Installer's Signature: f 104 Date: Z( &-Z&15 <br />Revision: 2 'f / 1 Monday, September 15, 2014 <br />