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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLlST <br />,1��-1 �vt, ��.�-iic.� � Sici-e. ��euseh', � _ _ _ <br />Instalfation Company Name and Contact lnfo: <br />Date Backwater Prevention device (BWD) was instalied <br />installation Property Owner Name and Contaet info: � <br />Praperty Address: <br />Date fhis form was <br />Pre-Installation Inspection Checklist: <br />All items must be checked `Yes` in order for a BWD fo be cansidered for installation <br />Is there a basemenf or level of the house that is at or near assumed sewer main elevation? [�'es ❑ No <br />Are fhere fixtures in the house located below the upstream sewer manhole rim elevatian? [�Yss ❑ No <br />Is the side sewer currently UIVPROTEC7ED from sewer backups (daes not have a BWD installed�?�Yes ❑ No <br />Site Inspection Checklist: <br />AU i�ems musf be checked `Yes' before rnspectron is consrdered complefe % <br />Was sjtle sewer TV inspected from building to sewer main? [� Yes ❑ No Condifian: _� r'�c� — <br />Does side sewer have at least 1% slope from the building to sewer main? [�`es ❑ No Descr�be: <br />r <br />Have all building sewer drain connections to the side sewer been identified and located? � Yes ❑ No <br />Have a{I property storm drainage cor�nections ta the side sewer been identified and located? �'Yes ❑ No <br />Nas property been evaluated for drainage deficiencies with findings communicated to property owner? �Yes ❑ No <br />Installation D�tails: � <br />What type and brand of BWD was installed at this site {C{ean Check SWV, Grinder pump, etc.): � <br />�9 P P)� �' �� /.�i n��° �' /1 � <br />Where was the device installed enera! descri tion, at�ach ma "r �=� +� --�� � o0 <br />Was there any other sewer or storm drainage wark completed in canjunction with the BWD work? fs so please describe: ` <br />lnstallation Checklist: <br />Are all downspou#s and site drainage disconrtected from upstream of the BWD? �'Yes ❑ No Comments: <br />Does BWD positioning meets minimum sVope requirement af >1%? � Yes ❑ No Comments: <br />Can BWD be pulled out for inspection antl maintenance after loosening thumb screw? [�es ❑ No <br />►s BWp locked into the proper position antl thumb screw tightened? �'es ❑ No <br />. ... <br />Circle the BWD cover. irrigation cover_(la scape area) ! traffic foatl bearing cover (dcive surface) I access hatch (buifding <br />Was property awner shown fhe location af ihe ins�alled BWD? �Yes ❑ No Comments: <br />Property Owner's Signature: <br />Installer's Signatu <br />Date: � <br />� <br />Date: � � `� <br />(� y �� % 1 Friday, September 12, 2014 <br />Revision: 2 � <br />