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'19 <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:,/?%'& (i, c7 j 5'7- /SG7 <br /> Date Backwater Prevention device (BWD)was installed: )/g/Zc/e Date this form was completed: <br /> Installation Property Owner Name and Contact Info: )G-o7 /3 cits-eo <br /> Property Address: /T+1' /Z ter— rue ire — 1,...,4, - / <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? 7 Yes No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? /I Yes n No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? /Yes n 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? [7Yes n No Condition: <br /> Does side sewer have at least 1% slope from the building to sewer main? 71 Yes ❑ No Describe: Z./. <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? n 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 'e(CH. eck B Grinder pump, etc.): <br /> Where was the device installed (general description, a ac map)? o/II('oe d1 Pry.?eE.ly <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? xi Yes n No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? j7(Yes n No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw?,Z Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? 71 Yes n No <br /> Circle the BWD cover ' ' anon cover(landsc p rea)/tra is ad bearing cover(drive surface)/access hatch (building) <br /> Was property owner shhc rrthe location of the ins'a ed BWD? 4'Yes C No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signat .......- - Date: / / /S"- <br /> Revision: 2 1 Monday,September 15;2014 <br />