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ACKWATER PREVENTIONDEVICE <br /> INSTALLATION CHECKLIST <br /> �ricun <br /> LC <br /> installation Company Name and Contact info ( re,!"4,24) S µ a�; r'ss f ?z-'X -4 <br /> Date Backwater Prevention device(BWD)was installed: % Date this.form was completed: j <br /> installation Property Owner Name and Contact Info: l-4 t_,' ';r✓�" k � iC <br /> Property Address: �. ��h 5 <br /> Preinstallation Inspection Checklist: <br /> All items-must be checked'Yes'in order for a BWD to be considered forinstallation <br /> is there a basement or level of the house that is at or near assumed sewer main elevation?0yes []No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? `es ❑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? Yes No Condition: 4^ <br /> Does side sewer have at least 9%slope'from.the building to 4ver main? 1'es ❑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 owrier? .[ 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)? see <br /> Was there any ather'sewer or,stonn 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 fl No Comments: <br /> Does BWDpositioning meets minimum slope requirement of>l%p? es ❑No Comments. <br /> Can BWD be pulled out for inspPrtion and maintenance after loosening thumb screw?" Yes E]No <br /> is BWD locked into the proper positron and thumb screw tightened? es ❑;No i <br /> i <br /> Circle the BWD cover rngatjon cUve landscape area)I traffic load 6earing cover(drive surface)t access hatch(building) <br /> Wqs property owner shown the location of the installed BWD? FYeS El No Comments: <br /> Property Owner's Signature: ���� ` �`�rg;.,d � `�. �Date: .� <br /> installer's Signatur ; - Date: 6 ` x , <br /> Revision:2 9., Friday,September 12,2014 <br />