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• IIIIP BACKWATER PREVENTION DEVICE FINAL <br /> Ira INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: -AMU-0 PLA.)irti3VOtt, 5126- 3 7 I A-67 <br /> Date Backwater Prevention device(BWD)was installed: (/1fii t 5 Date this form was completed: 1/11 i 15 <br /> Installation Property Owner Name and Contact Info: Left 14 4 tob-E9.50 0 yis-- :4443 91029 <br /> Property Address: /0 /7 flu VT MI( EV E 12-Er- IA)11- ?Re)2, / <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD to be considered for installation 1 <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?ra/s E No <br /> , <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? 'Yes - N <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?eYes El No <br /> c , <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? EfYes — No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? E'Yes [1 No D scribe: <br /> Have all building sewer drain connections to the side sewer been identified and located? m9escribe: <br /> Yes No <br /> Have all property storm drainage connections to the side sewer been identified and located? [7/Yes E. No , <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? FrY'es El No. <br /> Installation Details: <br /> What type and brand of BWD was installed at this site Clean Check BWV rinder pump,etc.): <br /> Where was the device installed(general description,attach map)? -,a4s,iciefiiOA/ IIcT <br /> =t„) Mci.. 1,1 fid <br /> Was there any other sewer or storm drainage,work completed in conjunction with the BWD work? Is so please describe: . <br /> -RE LIVE3 5,--‘0. 6 et ith-ck. 'TO- (r)ha i r ttfusr(1'11 PW) <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? il Yes 0 No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? 3 Yes 0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? rk yes No <br /> Is BWD locked into •- 6 I ler posi ion an® ' 6 '6 rew tightened? 67, es LI No _ <br /> Circle the BWD cover irrigation cover(landscape area traffic load bearing cover(drive surface)/access hatch (building) <br /> Was property owner shoTY - 'cation o t e insta led BWD? Yes E] No Comments: <br /> A 1 <br /> Property Owner's Signature: , Date: 1// by i S---- <br /> Installer's Signature: / '",f'„, rmEr Date: <br /> Revision:2 1 Monday,September 15,2014 <br /> I <br />