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BACKWATER4.7 PREVENTION DEVICEFINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: CA-01 P P1-04610 <br /> Date Backwater Prevention device (BWD)was installed: 121 tir Date this form was completed:_12#1 <br /> Installation Property Owner Name and Contact Info: kciAriz4613 pt PP <br /> 4 <br /> Property Address: L 1 Q2 C <br /> A CEDAl2., T T. ; t.1- LAJA4 <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? i !es j No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? E7Yes Q 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? es u No Condition: Elmet <br /> Does side sewer have at least 1%slope from the building to sewer main? 1 s n No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Yes No <br /> Have all property storm drainage connections to the side sewer been identified and located? s E No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? — No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump, etc): c1C--- <br /> Where was the device installed (general description, attach map)? irVP eaTiNct <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? <br /> . es r1 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? M es No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb� screw? ice'"Yes I I No <br /> Is BWD locked into the proper position and thumb screw tightened? CVYes _ No <br /> Circle the BWD cover:irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location of the installed BWD? (. es [11] No Comments: <br /> Property Owner's Signature' k/ .._.r Ag,/ / r,l, I� Date: 4.7°--6---/&/ <br /> -_ <br /> installer's Signature: .„4.111W <br /> ,4,�` <br /> - Date: 1-2.- <br /> Revision: 2 1 Monday, September 15, 2014 <br /> a <br />