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0: BACKWATER PREVENTION DEVICE FINAL <br /> 77 INSTALLATION CHECKLIST <br /> A mer-1 c"a 11 <br /> 1� Iza <br /> Installation Company Name and Contact Info: rl� aQ <br /> Date Backwater Prevention device(BWD)was installed: Date this form was comp <br /> �7 leted:—7 b <br /> Installation Property Owner Name and Contact Info: -450w -0e4 <br /> Property Address: <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? res [:] No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Ayes E] No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [ (es 0 No <br /> 7- <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? [ les 0 No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? P'es F❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Wes RNo <br /> Have all property storm drainage connections to the side sewer been identified and located? QXes []No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 1i'es ❑ No <br /> Installation Details: <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 wit the BWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? es ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? esNo Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumbscrew? �es ONo <br /> z. <br /> Is BWD locked into the pr ar-position,and thumbscrew tightened? 4:�PYes F_1No <br /> o I <br /> Circle the BWD cover nirriggatfion cover I scape area)I traffic load bearing cover(drive surface)I access hatch(bulldlng) <br /> Was property owner shown the location of the'installed BWD? P39s F1 No Comments: <br /> Property Owner's Signature: Date: <br /> Installers Signature: Date: <br /> Revi5ion:2 1 Friday, September 12,2014 <br />