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i 1 _ BACKWATER PREVENTION DEVICE FINAL ;Iii'Arigi INSTALLATION CHECKLIST . AMerican c -I- 9-ide Sec ' e t L Installation Company Name and Contact Info.:-Sec ai't-,e,(4;74)044) -QC/5V ay,) ,O9,05-sea Date Backwater Prevention device(BWD)was installed: 15-711s-- _Date this form was completed: 5? fel S' Installation Property Owner Name and Contact Info:3 P FF r`�',hoc [C �. , 1.a `a G"L / -` Property Address: aaoci0,4 (--1 C.,.tf --1 Ll EAQ c/1 R`:o I Pre-Installation Inspection Checklist: l All items must be checked'Yes'in order for a BWD to be considered for installation Is there a basement or level of the house that is at or near assumed sewer main elevation? (es Li No Are there fixtures in the house located below the upstream sewer manhole rim elevation? ,Yes [1 No Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? Wes I I No Site Inspection Checklist: All items must be checked'Yes'before inspection is considered complete / Was side sewer TV inspected from building to sewer main? 'es n No Condition: t (f.)C Does side sewer have at least 1%slope from the building to sewer main? 'es I I No Describe: Have all building sewer drain connections to the side sewer been identified and located? pi Yes ❑No Have all property storm drainage connections to the side sewer been identified and located? f Yes L[ No Has property been evaluated for drainage deficiencies with findings communicated to property owner? )2 Yes n No Installation Details: I type e and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): e,e4 St`ed) Where was the device installed (general description,attach map)? b. ( ' /' _� / - C I Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: it Installation Checklist: Are all downspouts and site drainage disconnected from upstream of the BWD? I 'es n No Comments: Does BWD positioning meets minimum slope requirement of'1%? `es I I No Comments: Can BWD be pulled out for inspection and maintenance after loosening thumb screw? es No Is BWD locked into the pro.er position and thumb screw tightened? RbYes Li No Circle the BWD cover: rigation cover :ndscape area)I traffic load bearing cover(drive surface)/access hatch (building) Was property owner shown the location of the installed BWD? J(es [1 No Comments: Y9 Property Owner'sSignature: Date: .q.--r L -4---P P Installer's Signature: - , Date: 8 t_ 5-- /5 Revis,ion:2 1 Friday,September 12,2014 I