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BACKWATER PREVENTION DEVICE FINAL <br /> , eg- INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: Mt pfwiikt LL[ 47,S=' i—o/Z 3 <br /> Date Backwater Prevention device(BWD)was installed: 4-2 l Date this form was completed: 4•--Go "—,5— <br /> Installation Property Owner Name and Contact Info: A duLvd-- 2 eAt r5S--e-a--- '312—`/g e8 <br /> Property Address: /0 O S e a.145 /11 <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?EiiKs f No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? es ❑No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? Rirel❑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? es ❑ No Condition: O/21 gi vt 1 45 iC <br /> Does side sewer have at least 1%slope from the building to sewer main? aY•o"s ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [tomes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? LLJ- es ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ru.Yes- ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): n <br /> Where was the device installed (general description, attach map)? C .ht(12_ J <br /> Was there any other sewer or storm drainage work crpleten conjunction with the BWD work? Is so please describe: <br /> ili <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? es ❑ No Comments: Am..., <br /> Does BWD positioning meets minimum slope requirement of>1%? 1.1-Ye ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ID-Yes ❑No <br /> Is BWD locked into the proper position and thumb screw tightened? [I 1 ❑No <br /> Circle the BWD cover: irrigation cover(landscape area) traffic load bearin cove rive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? L , i ❑No Comments: <br /> Property Owner's Signatur I Date: V 6 1.-C/5 <br /> Installer's Signature: Date: u1 t/ "f <br /> Revision: 2 1 Friday,September 12,2014 <br />