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F. <br /> 1 <br /> BACKWATER PREVENTION DEVICE FINAL <br /> 4IE7T <br /> INSTALLATION CHECKLIST <br /> 3 <br /> py i <br /> 3 L d <br /> Installation Company Name and Contact Info) '� .t�., <br /> Date Backwater Prevention device (BWD)was installed: Date this form was completed: I <br /> Installation Property Owner Name and Contact Info: areq <br /> Property Address: C <br /> Pre-installation Inspection Checklist: I <br /> L <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 ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [ 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? [ Yes ElNo Condition: Cl1 <br /> Does side sewer have at least 1%slope from the building to sewer main? es ❑ No Describe: <br /> F. <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? [ Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? Yes ❑ No '. <br /> Installation Details: <br /> I <br /> What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump,etc}.): ,} F- ( r <br /> Where was the device installed (general description, attach map)? "�' � '��k �7�--b ��e LE <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? Yes ❑No Comments: <br /> s <br /> Does BWD positioning meets minimum slope requirement of>1%? I�Pi'es ❑ No Comments: f <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? 5;111'es ❑ No _ <br /> Is BWD locked into the proper-position an thumb screw tightened? es ❑ No <br /> Circle the BWD cov : irrigation c ver I scape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the loc o of the instal BWD? Yes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> / z <br /> i <br /> Installer's Signature-_ Date: "1 -- <br /> 3 <br /> Revision:2 1 Friday,September 12, 2014 <br />