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gACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Inslalia6on Company Name a,id Conlact Info: l� ��/t'�� Yl- L QZ - 4$ - O/Z� <br /> Date Backwater Prevention device(BWD)was inslalled: Z-1 ate ihis fortn was completed:�2�� <br /> Inslailatfon Property Owner Neme and Contact Info: � .c��`►'�2_ 6 �"�-- <br /> Prope�ty Address.� 2-��` ST �L�P�'�C- <br /> Pre-Installa6on Inspection Checklist: <br /> All items must be checkeJ'Yes'in order for a 8WD fo be cnnsidered for instaJlafion <br /> Is ihere a basemenf or level of Ihe house thal is at or near assumed sewer main elevaGonl[�}Ye's ❑No <br /> Are Ihere fixtures in the house located below the upsVeam sewer manhole rim elevalion?[(�Y�s ❑No <br /> Is the side sewer curtently UNPROTECTEC(rum sewer hackups(does not have a BWD installed)?�]aGes ❑No <br /> Site Inspection Checklish <br /> All ilems musf be checked'Yes'before inspeclion is considered complele <br /> Was side sewer N inspected from building to sewer main? [�Ces- ❑No Condition: �N� L�-� ' <br /> Daes side sewer have at least 1% slope from the building to sewer main? [J,�,Yes� ❑No Describe: <br /> Have all building sewer drain conneclions to the side sewer been identfied and located? [�-1Fes ❑No <br /> Have all property storm drainage conneclions to the side sewer been idenMied and loceted? �Ces ❑No <br /> Has propeAy been evaluated for drainage deficiencies with findings comm�nicaled to property c,wner? �j.Yes-0 No <br /> Instailation DeWils: �� <br /> What type and brand of BWD was inslalled al Ihis sit Clean Check WV, Grinder pump,etc.): (�-�'u-GL'e-CL <br /> Where was lhe device installed (general description,a a map)? __V�'t''� '�-�- /h-� — <br /> Was ihere any other sewer or slortn�inagA v/�r�k�ple�ted in canjuncGon with the BWD work?Is so please describe:� <br /> � <br /> Installation Checklist: <br /> Are all downspouls and sile drainage disconnecled irom upsUeam of the BWD? es ❑No Commenls: <br /> Does 8WD positioning meets minimum slope requirement of>1%7 �s❑No Commenls: <br /> Can BWD be pulled oul for inspeclion and maintenance afler loosening lhumb screw? �es�(]No <br /> Is BWD loeked into the proper position an tighlened? [t}�es� �No <br /> Cirde ihe BWD cover: irrigation cover andscape area) lratfic load beering cover(drive surtace)f access hatch(building) <br /> Was property owner shown the localion of e-i talled BWO? �s�No Comments: <br /> Properly0wner'sSignature� Date: Y"' �'��.� <br /> Installers Signalure: Date: 'y-a �� <br /> Revision: 2 1 Friday,September 12,2014 <br />