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I <br /> e <br /> law 13ACKWATER PREVENTION DEVICE FINAL <br /> rr INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: J LLt 4 &(i;h 1~t, <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: / <br /> Installation Property Owner Name and Contact Info: ►`0, �f <br /> Property Address kfQy ► r , <br /> Pre-Installation Inspection Checklist: <br /> Ail 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? ILTYesC1No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? C"Yes ❑ N <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 coiplete <br /> 11 <br /> Was side sewer TV inspected from building to sewer main? [yes 0 No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? s ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? PYeY ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? [ es Q No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ' Yes ❑ No <br /> Installation Details: "'i <br /> What type and brand of 13WD was installed at this site(Clean Check BWV; Grinder pump,etc.): 9 <br /> r✓r rte <br /> Where was the device installed (general description, attach map)? _ r ; , �,; ," 4_�dr <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: T <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the WD? rYes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? Yes ❑ No Co ents: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? FL Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? EfYes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load aring cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the ins fed BWD? <br /> Vyes ❑ No Comments: <br /> Property Owner's Signature: _ _. Date <br /> Installer's Signature:g _ Date: <br /> Revision: 2 1 Monday,September 15,2014 <br />