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3 <br /> BACKWATER PREVENTION DEVICE FINAL <br /> 4wrr <br /> INSTALLATION CHECKLIST <br /> J <br /> 3 <br /> Installation Company Name and Contact Info."S (mo i["�� 42�')< - �f��+ � <br /> t <br /> Date Backwater Prevention device (BWD)was installed: Date this form was completed: <br /> Installation Property Owner Name and Contact Info: f XV .Q " - Q j <br /> i <br /> 3 <br /> Property Address: x. <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? S'es ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ( Yes ❑ No r <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? �7Yes L] No <br /> Site Inspection Checklist: <br /> Ail items must be checked `Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? IF Yes ❑ No Condition: G77� <br /> Does side sewer have at least 1% slope from the building to sewer main? [ t'es ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Yes ❑ No '. <br /> Have a[[ property storm drainage connections to the side sewer been identified and located? [ 'Yes [_1 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.): <br /> Where was the device installed (general description, attach ma 1 / <br /> i <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> Installation Checklist: r <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? jo'es El No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? es ❑ No Comments: <br /> Can BWD beulled out for inspection and maintenance after loosenin thumbscrew? es ❑ No <br /> p P <br /> x <br /> is BWD locked into the proper-.pos[tion_and thumb screw tightened? Yes [:] No' <br /> Circle the BWD co er: irrlgation cover(Ian cape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner -5elocation of the installed BWD? Yes ❑ No Comments: <br /> Date: <br /> Property Owners Signature: <br /> Installer's Signature —� Date: `— -7 _ <br /> Revision:2 1 Friday,September 12, 2014 <br />