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BACKWATER PREVENTION DEVICE FINAL <br />_J <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Into: U a rill r n Et O S f 'L l n11 r5 I10h I N C <br />Date Backwater Prevention device (BWD) was installed: I 1--2.L1Date this form was completed: <br />Installation Property Owner Name and Contact Into: •��lI jn' ilha Y+V 11r}S• 2e)Q <br />Property Address: fit k aIsk—_ F.OYQ - w h 99� ( <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? es [I No <br />Are (here fixtures in the house located below the upstream sewer manhole rim elevation? a es ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? Et -Ks ❑ 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? &res ❑ No C(j <br />Condition: " 61, " <br />Does side sewer have at least 1% slope from the building to sewer main? I� t es []No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? _ es ] No <br />40 <br />Have all property storm drainage connections to the side sewer been identified and Ps ❑ IJo <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? Yes ❑ No <br />Installation Details: I <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.):a. C6�a�(CG <br />Where was the device installed (general description, attach map)? jq��-A0 A-11h tAA6 <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 es ❑ No Comments: <br />Does BWD positioning;meets minimum slope requirement of >1%? es ❑ No <br />Can BWD be pulled out for inspection and maintenance after loosening Thumb screw? <br />ae <br />ms ts: _ <br />❑ Na <br />Is BWD locked into the proper position and thumb screw lightened? es ❑ No "*9* <br />Circle the BWD cover: irrigation covqqgdsca a are I traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? M,*ef-0 No Comments: A <br />Property Owner's Sir <br />Installer's Signature: <br />Revision: 2 <br />Date: <br />Date: 11 <br />lay, September 1S, 2014 <br />