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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHEC LIT <br /> Amrican <br /> Installation Company Name and Contact Info ? ; <br /> Date Backwater Prevention device (BWD)was installed: Date this form was completed: <br /> Installation Property Owner Name and Contact Info: I1 ,(C_f' ' \l `� r <br /> Property Address: IM �-�t FE—",.TAk.to Q & :L� <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? P'es ❑ 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? [PI'es ❑ No Condition: {4 �?cz J <br /> Does side sewer have at least 1%slope from the building to sewer main? 'fes ❑ 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? [ es ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? es ❑ 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 /> ) <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 ❑ No Comments: <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 ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? es [:] No' <br /> Circle the BWD cov . irrigation cover(la cape area)/traffic load bearingZo <br /> r(drive surface)/access hatch (building) <br /> Was property owners own the location of the installed WD? Yes Comments: <br /> n Date: (o <br /> Property Owners Signature: _ 1 <br /> Installer's Signature: Date: <br /> Revision:2 1 Friday,September 12,2014 <br /> i <br />