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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> L LC <br /> Installation Company Name and Contact Info: 12�):244-005t 2M' <br /> Date Backwater Prevention device(BWD) was installed: 116,, Date this form was completed: <br /> Installation Property Owner Name and Contact Info: <br /> Property Address: P � <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? D4%s ❑ No =. <br /> Are there fixtures in the house located below the upstream sewer manhole rim eievaflon?[ Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?PYes ❑ No <br /> Site Inspection Checklist: <br /> i <br /> All items must be checked`Yes'before inspection is considered complete ? <br /> inspected from building to sewer main? <br /> P <br /> Was side sewer TV ins Yes ❑ No Condition: GOD <br /> �' <br /> Does side sewer have at least 1%slope from the building to sewer main? �es ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [Oes ❑ 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.): i <br /> Where was the device installed (general description,attach map)? oma- 4 9 d <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 /> Does BWD positioning meets minimum slope requirement of>1%? Fi-q Yes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? Yes ❑ No <br /> Is BWD locked into the proper position [_and thumb screw tightened? ,Yes E] No <br /> Circle the BWD co : irrigation cover(I)dscape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property awn ri the location of the installed BWD? Yes ❑ No Comments: <br /> 014 <br /> Property Owner's Signature: <br /> Date: 7 / /�a <br /> —7 f <br /> Installer's Signat Date: -�--�? <br /> Revision:2 1 Friday,September 12, 2014 <br />