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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installaton Company Name and Contact Info: M0en r %, h: 1-1� 5 — 7 (, U -? 3 6 0 <br />Date Backwater Prevention device (BWD) was installed: Date this form was completed: 3 - I `7 —IT <br />Installation Property Owner Name and Contact Info: _�� /�� �� U� n ��.�k H2 S -(T s, <br />Properly Address: l —7I <br />Pre -Installation Inspection Checklist: <br />All items must be checked'Yes' in order for a BWD to be considered forinstallation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? N Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? P3'Yes []No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? F(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? [9Yes ❑ No Condition: ( un UY 42:1 <br />Does side sewer have at least 1% slope from the building to sewer main? 0 Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? OYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? Z Yes [1 No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? @ Yes [:]No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): <br />Where was the device installed (general description, attach map)? O(Jyl b_ 17. i� F <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 BWD7 ❑Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? N Yes []No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screvl?-❑ Yes-f©J P <br />Is 8WD locked into the proper position and thumb screw tightened? [)Yes �fde— <br />Circle the BWD cover. irrigation cover (landscape area) I traffic load bearing cover (drive surface) / access hatch (building) 1171q <br />Was property owner shown the location of the installed BWD? LYes ❑ No Comments: <br />Property Owner's Signature: Date: <br />Installers Signature: Date: <br />Revision: 2 1 Monday, September 15, 2014 <br />