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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info; C-ArvlP!E�Q.Ll <br /> Date Backwater Prevention device (BWD)was installed: Date this form was completed:._11 -7 -/ <br /> Installation Property Owner Name and Contact Info: <br /> Property Address: C - �. . �, Z7�1 - , f --- <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? [�Yyes ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? L_Xes ❑ N <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD,installed)? Yes ❑ No <br /> Site Inspection Checklist: <br /> t <br /> All items must be checked'Yes'before inspection is considered co j Iefe <br /> Was side sewer TV inspected from building to sewer main? ❑ Yes ❑ No ondition: <br /> Does side sewer have at least 1%slope from the building to sewer main? Yes ❑ Noescribe: <br /> Have all building sewer drain connections to the side sewer been identified and located? [/'J Yes . ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? [ Yes ❑ No. <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? [ Yes ❑ 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)? e -- 6-,,46e_ <br /> �/ w"I /l _ <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe;Ain <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? n Yes (_ o Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? (_ 'es No Comments: <br /> Can BIND be pulled out for inspection and maintenance after loosening thum screw? Yes ❑No <br /> Is BWD,locked into the proper po ition ngt um crewti tened? es ❑ No <br /> Circle the BWD cover: i r(laap a tra is load be rin <br /> g cover(d <br /> rive surface)/access hatch (building) <br /> Was properly owner shown the location of the installed BWD? ❑ Yes ❑ No Comments; 1, <br /> PrOpeity Owner's Signature:^, <br /> �.--- ' Date:,%G—/.S'" <br /> Installer's Signature: s <br /> Date: `�-l <br /> Revision: 2 1 Monday,September 15,2014 <br /> I <br />