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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact info: e-/) !'f� <br /> (un-,l7;'il 9 aC g--7 ) <br /> Date Backwater Prevention device(BWD)was installed: -I s= I <br /> Date this form was completed: �-C <br /> installation Property Owner Name and Contact Info: Par. C o 1 et.,,, <br /> Property Address: - <br /> Pre.lnstallation 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?E Yes E No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?Q Yes ❑No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? 1'1 Yes ❑No <br /> Site Inspection Checklist: grbk-e-^ <br /> Ail items must be checked'Yes'before inspection Is considered complete <br /> Was side sewer TV inspected from building to sewer main? 'Yes ❑No Condition: c.Pc -f--- <br /> Does side sewer have at least 1%slope from the building to sewer main? 3 Yes ❑No Describe; <br /> Have all building sewer drain connections to the side sewer been idenfified and located? El Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? ( 'Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? I Yes ❑ No <br /> installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): 1 I <br /> Where was the device Installed(general description, attach map)? w•-e--ri -- <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe;— <br /> 711713- <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? KiYes ❑No Comments: <br /> Does BWD positioning meets minimum slope requirement of 51%? E Yes n No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? l <br /> is BWD locked into the proper position and thumb screw tightened? <br /> Circle the BWD cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch(building) '1 <br /> i <br /> Was property owner shown the location of the installed BWD? fYes ❑ No Comments: <br /> Property Owner's Signature: Date: <br /> Installer's Signature: �� `�� Date: —is-- <br /> Revision: <br /> is=Revision:2 1 Monday,September 15,2014 <br />