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BACKWATER PREVENTION DEVICE FINAL. <br /> INSTALLATION CHECKLIST <br /> Stallation Company Name and Contact Info: G' i fir' / 2 el <br /> Date Backwater Prevention device(BWD)was installed: Date this torm was comoiece_ <br /> Installation Property Owner Name and Contact Info, i a k, <br /> Property Address: --z--z-a � <br /> c , <br /> i <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? es ❑Na <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?Q ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? es ❑ No <br /> Site Inspection Checklist: <br /> 3 <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 leash 1,%slope ftom,the bg,ilding toseyver.main?, es ❑No Describe: <br /> Have all building sewer drain connections to the side sevVer beet', identified and located? D�-ASso 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?---Q-Yeg- ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV Grinder pump,etc.): CIAL,.(�- ' <br /> Where was the device installed (general description, attach map)? <br /> Was there anv other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe: <br /> iv(5 - <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? M-'fes ❑No Comment <br /> Does BWD positioning meets minimum slope requirement of>1%? MYL5s ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? s ❑No <br /> Is BWD locked into the proper position d , ew tightened? [ms's'❑No--- - <br /> Circle the BWD cover:irrigation c ver(landscape areal affic loadbear', cover(drive surface)1 access hatch (building) <br /> Was property owner shown theJ on o installed BWD? es ❑No Comments: <br /> JI— <br /> Property Owner's Signature:(5 Date: <br /> Installer's Signature: I <br /> Date: <br /> Revision: 2 1 Friday,September 12,2014 <br />