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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST � <br /> 7 <br /> Installation Company Name and Contact Info: *ifin Prior r), 5� = S87—�5"f�9 <br /> Date Backwater Prevention device (BWD)was installed:qer Ty t Date this form was completed: ''24ik 1-4 <br /> Installation Property Owner Name and Contact Info: 91,171,1 - 1?011.-OKIAt <br /> Property Address:' l IP -r4 •c\i 69,, — ._ + t' . 4146 2I - <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 basement or level of the house that is at or near assumed sewer main elevation? X Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ® Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? KC 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? ®Yes E No Condition: <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? n Yes n No <br /> Have all property storm drainage connections to the side sewer been identified and located? ❑ Yes [ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? Lj 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)? t•It r t 5 4 H2s-( <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> -i. Arraf- Un,I O 2.Q - T2tA, Appii,e Ezttmi /nr6 <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? ❑ Yes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? ❑Yes ❑ 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 thumb screw tightened? n Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? ❑Yes [ No Comments: <br /> Property Owner's Signature ,— Date: d2.If711 4 <br /> Installer's Signature: O Date: <br /> Revision: 2 • 1 Friday, September 12, 2014 <br />