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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info., <br /> i-ce 1"4 <br /> Date Backwater Prevention device (BWD)was installed: '?/,?,V�7 Date this form was completed:`74)1!�bl' <br /> Installation Property Owner Name and Contact Info: KV5UJ <br /> Property Address: aOLt� 1 <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? ryes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevafion? Ryes FJNo <br /> Is the side sewer Currently UNPROTECTED from sewer backups (does not have a BWD installed)? es ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked Yes'beforo inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? [�es El No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? les n No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? f;P(es n No <br /> Have all property storm drainage connections to the side sewer been identified and located? [;CCYes E]No <br /> Has property been evaluated for drainage deficiencies with findings.communicated to property owner? 9-;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 map)? <br /> Was there any other sewer or storm drainage work completed in conjunction wit the BWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? es n No Comments: <br /> F-1,,,Y <br /> Does BWD positioning meets minimum slope requirement of>1%? es No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? �es El No <br /> Is BWD locked into thepr ar-position-and thumbscrew tightened? Q:�Yes F1 No <br /> o""o' <br /> Circle the BWD cover irrigation cover I _scape area)/traffic load bearing cover(drive surface)I access hatch(bulldlng) <br /> Was property owner shown the location of the installed BWD? s [] No Comments. <br /> Property Owner's Signature: Date: <br /> Installers Signature- Date: <br /> Revis'ion:2 1 Friday, September 12,2014 <br /> ............................... <br />