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- 0477. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: cTioer file44,7e, <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: <br /> / 2-411 '4 <br /> Installation Property Owner Name and Contact Info: - . ck ?e\`J°'` N t <br /> Property Address: t52: 1.. r k <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? d Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? rv. Yes ❑No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? Yes ❑ No <br /> Site Inspection Checklist: <br /> Al!items must be checked'Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? 'I%Yes ❑ No Condition: Yo tAi3 <br /> Does side sewer have at least 1%slope from the building to sewer main? Yes ❑ No Describe: Ii V`t-- <br /> Have all building sewer drain connections to the side sewer been identified and located? Yes ❑ 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? [ Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): elgUrt C 41 <br /> Where was the device installed(general description, attach map)? l t S i ttej ti -'1/D of- <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> NYVVe.ift "CAN-e71-. <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? t Yes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? jJ 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? Yes ❑ No <br /> Circle the BWD cover: . ' anon cover(landscape area /traffic load bearing cover(drive surface)I access hatch(building) <br /> Was property owner shown the location of the installed BWD? Vj Yes ❑ No Comments: <br /> Property Owner's Signature: <br /> nature: Date: l <br /> Installer's Signatures'// ' r� - Date: t ItOO <br /> 1 1 <br /> Revision:2 1 Friday,September 12,2014 <br />