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i <br /> BACKWATER PREVENTION DEVICE FINAL <br /> ii <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info-T e iq� <br /> Date Backwater Prevention device (BWD)was installed: VfImo...Date this form was completed: '7111 j <br /> Installation Property Owner Name and Contact Info:`r� ,{r}, � �' `� �^" __ 1�� <br /> 5 <br /> Property Address; , <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? E -Yes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?des ❑ 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? [ 'es ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? [ Nes ❑ 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.): Y`c { <br /> Where was the device installed (general description, attach map)? 124::S &I <br /> i <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? [Wes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? files ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? �'es ❑ No <br /> Is BWD locked into the pro !tion and thumbscrew tightened? �'es ❑ No <br /> Circle the BWD cover: irigation_c:ove Wscape area)/traffic load bearing cover(drive surface)I access hatch (building) <br /> Was property owner shown the location of the installed BWD? [Xes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature- Date: <br /> Revision: 2 1 Friday, September 12, 2014 <br />