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BACKWATER PREVENTION DEVICE FINAL <br /> ✓4tii - INSTALLATION CHECKLIST <br /> A mi Ic er 5-icte S cce,r L L C <br /> Installation Company Name and Contact fo:f>f C If (_„.1.. "'6" 'r. ' a' '' ' ' ) <br /> Date Backwater Prevention device(BWD)was installed: 5 lel Date this form was completed: tdaii< <br /> Installation Property Owner Name and Contact Info: (610 ti:t 4Q5 c�J <br /> p KP Pei -Q , ��PA 0.4" q g 0 IProperty Address: Q.0 � � i <br /> Pro-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? {Yes E. 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 �GC1 Yi: <br /> Was side sewer TV inspected from building to sewer main? ?Nes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? re-ales 111No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [ Yes IT No <br /> Have all property storm drainage connections to the side sewer been identified and located? [7Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? JYes I No <br /> Installation Details: �} <br /> type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): 4cicir Soc4 <br /> What / <br /> Where was the device installed (general description,attach map)? See C (J' L tat t <br /> Was there any other sewer or storm drainage work completed in conjunc ion with the BWD work? Is so please describe:— <br /> /\ <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%? ?es I I No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? les C No <br /> Is BWD locked into the proper position and thumb screw tightened? pYes ❑ No <br /> Circle the BWD cover irrigation cover dscape area)/traffic load bearing cover(drive surface)I access hatch(building) <br /> Was property owner shown the local:' of il.talled BWD? (P(es U No Comments: <br /> /� Date: G, / 1 <br /> Property Owner's Signature: AL11~---11Installer's Signature: <br /> Date: 6 Mr <br /> Revision:2 1 Friday,September 12,2014 <br /> 3 <br />