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O;LBACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION <br /> Installation Company Name and Contact Info: a - , <br /> Date Backwater Prevention device(BWD)was installed:q Date this form was completed: <br /> Installation Property Ower Name and Contact Info: <br /> Property Address: <br /> Pro-Installation Inspection Ch ist: <br /> All items must be checked'Yes'in order for a BIMD to be considered 1br installation <br /> is there a basement or level of the house that is at or near assumed sewer main elevation?Dliis ❑No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?Oles [:]N No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?❑YOt ❑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? i es❑No Condition: <br /> Does side sewer have at least 1%Slope from the building to sewer main? 0-Yes ❑No Desc e: <br /> Have all building sewer drain connections to the side sewer been identified and located? ❑,'es ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? 6- ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? [1-Yes ❑No <br /> Installation Details: 'p u <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): <br /> Where was the device installed(general description,attach map)? <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? es nolo Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? ❑Yves ❑No Comments; <br /> Can BWD be pulled out for inspection and maintenance atter loosening thumb screw? ❑Yes ❑No <br /> Is BWD locked into the proper position an skew tightened? [9--Yes ❑No <br /> Circle the BWD cover: irrigation covr(landscape area -traffic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the location/0 the installed BWD? s' ❑No Comments: <br /> Property Owner's Signature, Date: <br /> Installer's Signature. I" 1� �° -- Date: _ _ <br /> Revision:2 1 Friday,September 12,2014 i <br /> E <br />