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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> 4-EIT'' I <br /> Installation Company Name and Contact Info: e_.,401.P F.,LLS Pi--um r ifo(-4 _> IN ( <br /> Date Backwater Prevention device (BWD)was installed: L\, I-1 ` )t Date this form was completed: (. q i S- <br /> I nsta I I ati o n <br /> -Installation Property Owner Name and Contact Info: V SA p t :g_ 1 ,1 ,QcE,J <br /> Property Address: `2=32' V(12414 a fisc A,,;C.) ever_e-n- u.„-tN, `"t° 2-6\ <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? s I I No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? es No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? s — No <br /> Site Inspection Checklist: <br /> All items must be checked 'Yes'before inspection is considered com fete <br /> Was side sewer TV inspected from building to sewer main? Yes _ No Co clition: <br /> Does side sewer have at least 1%slope from the building to sewer main? Yes fl No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? I ves I I No <br /> Have all property storm drainage connections to the side sewer been identified and located? s [ I No , <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? (t es — No <br /> Installation Details: [ <br /> What type and brand.of BWD was installed at this site(Clean Check BWV, Grinder pump, etc.): (Ip ,,,, C i. ,,i __. <br /> Where was the device installed (general description, attach map)? I H ) <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? [i Yes [9ivo Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? TeS I I No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? (- -s I I No <br /> Is BWD locked into the proper position and thumb screw tightened? es I I No <br /> Circle the BWD cover: irrigation cove landscape area) traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shown the location o t a installed BWD? es I I No Comments: <br /> Property Owner's Signature. / fooi <br /> / G`- .. 4't4-&1-'l Date: i/ / go 15 <br /> Installer's Signature: �- ,m` Date: 1 I SI j <br /> Revision: 2 1 Monday,September 15, 2014 <br />