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0001111P0' BACKWATER PREVENTION DEVICE FINAL <br /> 41 Lial INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: Ain fl-h t.A-,,ct€c-it.- Air J..) r fyiNci*---3 ,t erc-,-.4,t,,,i. gv,_ L <br /> Date Backwater Prevention device(BWD)was installed: '6P.5*/ ..01>‘Date this form was completed: 9//rfro/7 <br /> Installation Property Owner Name and Contact Info: Mtn Itit Nix> <br /> ixp... <br /> Property Address: )6.0 1 4 1 1 54- 5 <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?0 Yes n No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?1E Yes 0 No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?2 Yes 0 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? El Yes 0 No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? VII Yes El No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? Yes El No <br /> Have all property storm drainage connections to the side sewer been identified and located? Es Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 0 Yes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): <br /> Where was the device installed(general description,attach map)? <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe:_rip <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? i71. Yes n No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? Yes 0 No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? rig Yes 0 No <br /> Is BWD locked into the proper position and thumb screw tightened? rAYes D No <br /> Circle the BWD cover:irrigation cover(landscape area)I traffic load bearing cover(drive surface) <br /> Was property owner shown the location of the installed BWD? g Yes 0 No Comments: <br /> Property Owner's Signature: c- -4,11-1 / / Date: IA /31 1 0 <br /> Installer's Signature: -, ',- e".-)1.:-/,--y:' ,7 .:-' - :://k' Date: 11 1 1 11 <br /> Revision:2 1 Friday,September 12,2014 <br />