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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: ., i'11 i r-? 1,L, �� ,T 1 &J . <br /> Date Backwater Prevention device (BWD)was installed: i _2,0/ Date this form was completed: <br /> Inst=allation Property Owner Name and Contact Info: 1 <br /> Property Address: //0-7 PU#Z1/<e4z, <br /> Pre-Installation inspection Checklist: <br /> Ali items must be checked'Yes'in order for a BWD to be considered for installation <br /> Is there abasement or level of the house that is at or near assumed sewer main elevation? 1:9 Yes ❑ No <br /> 11 <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?Fj]Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?Comes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked `Yes'before inspection is considered complete t <br /> w. <br /> Was side sewer TV inspected from building to sewer main? (. Yes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? ��•�e <br /> s ❑ No Describe: <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? [ Yes [] No i <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? Yes F1 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this sit Clean Check BWV rinder pump, etc.): i <br /> Where was the device installed (general description, attach map)? _ i <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 theVes <br /> ? Yes �] No Comments: <br /> Does BWD positioning meets minimum slope requirement of>l%? ( [j No Comments: <br /> Can BWD be pulled out for inspection and maintonance after loosening thumb screw? Yes ❑ No <br /> Is BWD locked into Cthe7" ro nd thumb screw tightened? FqY s ❑ No <br /> Cirde the BWD covver ndscape area)/traffic lgs <br /> acing cover(drive surface)/access hatch(buildincg) <br /> Was property ownelocation of the installed BWD? ❑No Comments: <br /> k <br /> Property Owner's Signature: � °� " <br /> � � Date: <br /> Installer's Signature: 2 ! , r_ Date: f 5 <br /> Revision:2 1 Monday,September 15, 2014 <br />