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er.._,:., 0 <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: H 0 ell 17(1.-1,-117;,1 9 9.5.- 7L,0 E-760 <br /> Date Backwater Prevention device(BWD)was installed: k—(( <br /> --i Date this form was completed: If-rc w r S— <br /> installation Property Owner Name and Contact Info: Pe. (20- (1 ( _r"- _-1-. 415--- 7 7 1 S s <br /> Property Address: a 3 i .�S A 5-(ff <br /> r <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?2 Yes [ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ii Yes 0 No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? Ei Yes I I 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? Igt Yes <br /> ❑No Condition: I {r 7 . <br /> Does side sewer have at least 1% slope from the building to sewer main? E]Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Q Yes 0 No <br /> Have all property storm drainage connections to the side sewer been identified and located? l Yes 0 No <br /> I?Has property been evaluated for drainage deficiencies with findings communicated to property owner? tij Yes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): C(ed-, c: L ccs Where was the device installed(general description,attach map)? (---' ff s, ck-- 1, ,,..5'<-- <br /> • <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe:— <br /> //k, - <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? I Yes U No Comments: <br /> Does BWD positioning meets minimum slope requirement of 51%? RYes 0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? Q Yes El No <br /> is BWD locked into the proper position and thumb screw tightened? [E Yes ❑ No <br /> Circle the BWD cover. i aion cover ndscape area)/traffic load bearing cover(drive surface)I access hatch(building) <br /> Was property owner shown the location of the installed BWD? El Yes ❑No Comments: <br /> Property Owner's Signature: Date: <br /> installer's Signature: `1- —/ .' Date: '�t c)'/S.-- <br /> Revision: <br /> S.Revision:2 1 Monday,September 15,2014 <br />