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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> A olen can &-t <br /> A <br /> 2 <br /> Installation Company Name and Contact Info <br /> Date Backwater Prevention device(BWD)was installed:. Date this form was completed: <br /> 41 <br /> -ok _cz�4d-_ <br /> Installation Property Owner Name and Contact Info: FLiew_# 14, (U <br /> Property Address: 1 'F--c <br /> ( )� { q <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??Yes E] No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes E] No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have BWD installed)? P 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? NYes ONo Condition: &M <br /> N <br /> Does side sewer have at least I%slope from the building to sewer main? � Yes L] No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [ 'Yes E]No <br /> Have all property storm drainage connections to the side sewer been identified and located?( Yes n No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property wrier? P-Yes E]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)? S(�eJJ�ZC_I�U) <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? es 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? UYes EINo Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? ElYes F1No, <br /> Is BWD locked into the properTosition and thumb screw tightened? Yes [] No' <br /> Circle the BWD cover:Crigationcovet(la scape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the�o a cover <br /> of the installed BWD? Ryes ❑ No Comments* <br /> Property Owner's Signature: Date: <br /> Installer's Signature.- Date: <br /> Revision:2 1 Friday,September 12,2014 <br />