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BACKWATER PREVENTION DEVICE FINAL <br />0� INSTALLATION CHECKLIST am <br />Installation Company Name and Contact Info: l Ar11 V 6 !7 LL' )� T L-0 16 IU:) i r — <br />Date Backwater Prevention device (BWD) was installed: j % JJ Dale this form was completed: <br />Installation Property Owner Name and Contact Info:PlYtTk CQ25 �ZS2- 2Co`]�o <br />Property Address: rfye, ce.'ir <br />Pre•Installp2lon Inspection Checklist: <br />All items mvA 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 etc vationJes <br />s ElNo <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? ❑ N <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�plele / <br />Was side sewer TV inspected from building t sewer main? es ❑ No C ndition: G—rrz�D <br />Does side sewer have at least 1% slope from the building to sewer main? Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? U Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? � fes ❑ NO <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [L�'�es [:]No <br />Installation Details: <br />What type and brand of BWD was installed at this site Clean Check BIM/ Grinder pump, etc.): 61e w LLJC <br />Where was thVe0i a installed (general description, attach map)? A163 r .S P' - 61" u.C� <br />1 Gri,Ire �. 1-4�wc� l,l '`r �/'om rUar tsl /:,��ritar' C7��/7�oN <br />p 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 DWD? es ❑ % Comments: <br />Does BWD positioning meets minimum slope requirement of >1%? Yes ❑ No <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? <br />Comments: _ <br />es ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? Ln Yes ❑ No rdrf C„ie /< <br />Circle the BWD cover: irrigation cover (landscape area) i traffic load baring cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? Yes ❑ No Comments: <br />Property Owner's Signature: <br />Installers Signature: <br />Revision: 2 <br />Date: Y S / <br />Date: <br />Monday, September 1S, 2014 <br />