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i <br /> 3 <br /> 4.77. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST = <br /> ff __ <br /> Installation Company Name and Contact Info: /u 01 La/Pti j_L( J-- `t ?-6/Z 3 2 <br /> Date Backwater Prevention device(BWD)was installed: .3_1 t "this form was completed: RA 8 t S <br /> Installation Property Owner Name and Contact Info: _ �� �'t�r—r ' - <br /> Property Address: "2-\k,' j3� T ' 6T 'f -( W4- <br /> Pre-Installation <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? es ❑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)?[tis 0 No <br /> Site Inspection Checklist: <br /> Al!items must be checked Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? [tom'[]No Condition: Q.s, 6 4 CS4 ik - <br /> Does side sewer have at least 1%slope from the building to sewer main? D-'1' s ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? 0 No <br /> Have all property storm drainage connections to the side sewer been identified and located? ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? [ tis ❑ No <br /> installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV_Gander numn etc 1:_. l " el <br /> (56';1 <br /> (---(--- -1� 1 or 6,"z .e "y, <br /> - j'n .6)-".1A-43 <br /> * P--241Hut- <br /> ♦ �1 v[irr iw�T-r . ..- - - - - r <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? Eh s 0 No Comments:, ai. <br /> Does BWD positioning meets minimum slope requirement of>1%? es ❑ No Comments: °&" <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? [ s 0 No <br /> Is BWD locked into the proper position and thumb screw tightened? aYes 0 No <br /> Circle the BWD cover:irrigation cover(landscape area) traffic load bearing cover drive surface)I access hatch(building) <br /> Was property owner shown the location o'the installed BWD? [ 61 ❑No Comments: <br /> Property Owner's Si,I_ . -. .v Date: 8�--t -1^i <br /> co <br /> Installer's Signa01//_ __) Date: flt, 'ic— I S <br /> Revision:2 1 Friday,September 12,2014 <br /> I <br />