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• <br /> . , <br /> ,,,,,,,_... BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: 4i9,e7"/a 744,-7gi_rf <br /> Date Backwater Prevention device(BWD)was installed: L/`///, Date this form was completed: 2 /f/> <br /> Installation Property Owner Name and Contact Info: h✓f5' ,feel <br /> Property.Address: /,/lam' '75 x1 <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? Yes 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes 0 No <br /> • Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?g 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? feYes ❑No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? ,Et Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ]Yes 0 No <br /> Have all property storm drainage connections to the side sewer been identified and located? j2rYes ❑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.): ..<>1r,,2�✓e P"c. 864V <br /> Where was the device installed (general description,attach map)? jis5f /e7S 4 P 61-- is> e P e� 7aie <br /> I h e it/9 404 <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? ,e Yes 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%?;2Yes 0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? "Yes ❑No <br /> Is BWD locked into the proper position and u u• ew tightened? ,'Yes 0 No <br /> Circle the BWD • . mgation cover la,• .,:•- . -=` +a' c load bearing cover(drive surface)/access hatch(building) <br /> Was property owner s own the location of the installed BWD? Yes 0 No Comments: <br /> Property Owner's Signature: Date: (-4 " <br /> Installer's Signature: Date: 4/32/ / <br /> Revision:2 1 Friday,September 12,2014 <br />