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BACKWATER PREVENTION DEVICE FINAL <br /> 4.77, <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: 62,iik iphetts r(4,41,e A9 <br /> Date Backwater Prevention device (BWD)was installed: i 1—)1—[-( Date this form was completed: 1,122(.0-1(f <br /> Installation Property Owner Name and Contact Info: --; 0 r abrivit 1\ <br /> Property Address: i-c� " - = i. v�'-` i 4 o <br /> Pre-Installation Inspection neck t /44 "1"1-- <br /> All <br /> -- <br /> All items must be checked Yes'in order fora 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? r Yes <br /> Li No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ,%rYes I I No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? KYes — 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? f7r(es 1 I No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? f Yes n No <br /> Have all property storm drainage connections to the side sewer been identified and located? 7Yes P1 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? i'Yes T No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site Clean Check B' , Grinder pump, etc.): <br /> Where was the device installed (general description, attach map)? MIA-1P j9 <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? Yes LI No Comments: 1 <br /> Does BWD positioning meets minimum slope requirement of>1%? 'Yes P No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? 71 Yes I I No <br /> Is BWD locked into the proper position and thumb screw tightened? i" Yes ( I No <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch (building) j <br /> Was property owner shown the location of the installed BWD? `l Yes ,+ No Comments: f <br /> Property Owner's Signature: ,ii ✓ t� C04.1�, . ,/, ,,,� Dat I//u i i�f' <br /> ___________ <br /> Installer's Signature: Date: i/1'/2C;7i-l% <br /> Revision: 2 1 Monday,September 15, 2014 <br /> 1 <br /> I <br />