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3 <br /> z <br /> BACKWATER PREVENTION DEVICE FINAL j <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info':aeu Ar.C% <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: 6 <br /> Installation Property Owner Name and Contact Info:) kck�,Iiyvyn� � <br /> Property Address: <br /> i <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? X•Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? F 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? V Yes [:] No Condition- C_XXA <br /> y.. <br /> Does side sewer have at least 1%slope from the building to sewer main? QgYes ❑ No Describe: <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 /> What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): OF&E G <br /> "-�k <br /> Where was the device installed (general description, attach map)? { <br /> Was there any other sewer or storm drainage work com feted in conjunction with the BWD work? is so please describe:_ <br /> Installation Checklist: <br /> 3 <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? Wes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? (Wes [:] No Comments: <br /> f <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? [ Yes [] No <br /> Is BWD locked into the prop-ar..positLon and thumbscrew tightened? ETYes ❑ No <br /> Circle the BWD cov!I:�irrrlLationcover andscape area)/traffic load bearing cover(drive surface)1 access hatch (building) <br /> Was property owner shown the location of the installed BWD? Wes ❑ No Comments: <br /> ' Signature:Property Owner's Signa Date:r . <br /> Installer's Signature: Date: 2 i <br /> i <br /> Revision:2 1 Friday,September 12,2014 <br /> x <br />