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BACKWATER PREVENTION DEVICE ANAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: /479- /2/; i t .17 (6 c_ 42j-- 'MI— <br /> Date Backwater Prevention device(BWD)was installed:a_ -1 - Date this form was completed: <br /> Installation Property Property Owner Name and Contact Info:`---th 0-44- 7-Y01-3 .? <br /> Property Address: c. 76`) ee,e6e/ <br /> Pre,,Installation Inspection Checklist: <br /> All items must be checked'Yee 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?ve<11 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?[LleY‹ ri No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?[DX‘ri 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? [Balfri- 0 No Condition: Ore? ej-1/1-12-X <br /> (27 <br /> Does side sewer have at least 1% slope from the building to sewer main? CiPtis n No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? I-Yes FA No <br /> Have all property storm drainage connections to the side sewer been identified and located? III-Ves n No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? El-Yes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check I3WV,Grinder pump,etc.): :" <br /> Where was the device installed(general des 'ption,attach map)? _sc:;_e_e_ fil‘e12 <br /> l/r-tx-e-e7 <br /> Was there any other sewer or storm drainage work completed in with the BWD work?Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? Cawtsg'D No Comments: 0-(3)"-e <br /> Does BWD positioning meets minimum slope requirement of>1%? EGA< 0 No Comments: 2 1.‘ e-, <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? 0.-Yesse No <br /> Is BWD locked into the proper position and thumb screw ti,h ened? IP! - . 111 No <br /> Circle the BWD cover:irrigation cover(landscape area I traffic load bearing cover(I.'ve surface)/access hatch(building) <br /> Was property owner shown the location of the installed BWD? Ii $ No Comments: <br /> Property Owner's Signatur Date:_ <br /> Installer's Signature: /71-1( C <br /> Date: 4-7-2—/ <br /> Revision:2 1 Friday,September 12,2014 <br />