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C <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> AMO can <br /> L- LC <br /> Installation Company Name and Contact Info��C-P Id i-ce l r a)2�4 4 ,5f-d 01i J'?"i(i <br /> Date Backwater Prevention device (BWD)was installed: Date this form was completed:cQ <br /> Installation Property Owner Name and Contact Info: > v`J 4 ti <br /> Property Address: i <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked `Yes'in order for a BWD to be considered for installation <br /> z <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation? VYes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ( `Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? �j Yes ❑ No <br /> Site Inspection Checklist: <br /> r <br /> All items must be checked `Yes'before inspection is considered complete <br /> i~ <br /> Was side sewer TV inspected from building to sewer main? Yes E] No Condition: � cze <br /> Does side sewer have at least 1%slope from the building to sewer main? FVYes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [ 'Yes ❑No <br /> 1 <br /> Have all property storm drainage connections to the side sewer been identified and located? '4Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? F2ryes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump, etc.): 4�(� � <br /> Where was the device installed(general description,attach map)? <PFroof ,45 <br /> Was there any other sewer or storm drainage work completed in c nirunncti n with the BWD work?Is so please describe: <br /> Installation Checklist: } <br /> 1 <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? WYes ❑No Comments: I <br /> Does BWD positioning meets minimum slope requirement of>1%? 'oYes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? (VYes ❑ No <br /> Is BWD locked into the proper position and thumbscrew tightened? KYes ❑ No <br /> Circle the BWD cove : irrigation cover landscape area)/traffic load bearing cover(drive surface)I access hatch (building) <br /> Waspropertyowners own a ocation of the installed BWD? [�Yes No Comments: <br /> I� ❑ <br /> 3 <br /> Property Owner's Signature: Date: <br /> ,9I <br /> Installer's Signature: Date: '" Gt5 ' 2t)t S <br /> Revision:2 1 Friday,September 12,2014 <br /> i <br />