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BACKWATER <br />INSTALLATION <br />Installation Company Name and Contact Info: <br />, <br />Date Backwater Prevention device (BWD) was installed. <br />Date this form was completed: �EO— ? S' <br />Installation Propery Owner Name and Contact Info: <br />Properly Address: /�% %'�c CK�,;' <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? K Yes [:]No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? ® Yes El No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? ® Yes ❑ 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? © Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? o Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? 9 Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? M Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): Git?1 Cr <br />Where was the device installed (general description, attach map)? hP <br />OL A&1 �IfM�C>> <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? Z Yes ❑ No Comments: <br />Does B1ND positioning meets minimum slope requirement of >1 %? KJYes �— <br />Can BWD be pulled out for inspection and maintenance after loosening thumb �ew? Comments: <br />Is BWD locked into the Proper ositi 7(lan <br />,,®Yes ❑N0p P P b screw tightened? [Z } es ❑ No <br />Circle the BWD cover: irriga#ion c vdscape area raf is load bearingcover (drive <br />Was property owner shown the location of t e installed BWD? ( ve surface) access hatch (building) <br />,� Yes ❑ No Comments: <br />Property Owner's Signature: <br />Date: !E -- .2 p f S <br />Installer's Signatur,���j_ <br />Date: <br />Revision: 2 <br />Friday, September 12, 2014 <br />