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1 <br /> BACKWATER PREVENTION DEVICE FINAL. <br /> Ev INSTALLATION CHECKLIST { <br /> Installation Company Name and Contact Info: -Z 1 J. <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: <br /> Installation Property Owner Name and Contact Info: ). ' <br /> i <br /> Property Address: V"Y)C Q42=tk i )slo zi __A&1- � <br /> Pre-Installation Inspection Checklist: l <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 [] 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 /> t <br /> Site Inspection Checklist: j <br /> r <br /> All items must be checked Yes'before inspection is considered complete j <br /> Was side sewer TV inspected from building to sewer main? � yI <br /> es El No Condition: I-ct <br /> Does side sewer have at least 1%slope from the building to sewer main? ( 'Yes ❑ No Describe. <br /> Have all building sewer drain connections to the side sewer been identified and located? [ 'Yes ❑ No Y <br /> Have all property storm drainage connections to the side sewer been identified and located? E�Xes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? es ❑ No <br /> Installation Details: } <br /> What type <br /> 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 /> x <br /> Was there any other sewer or storm drainage work completed in conjunction with t e BWDwork? is so please describe: <br /> Installation Checklist: <br /> s <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? RYes ❑ No Comments: 3 <br /> i <br /> Does BWD positioning meets minimum slope requirement of>1%? 'Yes. ❑ No Comments: <br /> E <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? [�O�es ❑ No <br /> 1 <br /> Is BWD locked into thepr '-position-and thumb screw tightened? lx];Yes L] No <br /> Circle the BWD co r: irrigation cover(l)dscape area)I traffic load bearing cover (drive surface)1 access hatch (building) #. <br /> Was property owner shown the location of the installed BWD? PYes EJ No Comments: <br /> / 2 <br /> Property Owner's Signature: Date: r a <br /> Installer's Signature: Date: <br /> Revision:2 1 Friday,September 12,2014 <br />