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I <br /> BACKWATER PREVENTION. DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> 12601 „Li 1„.7_ ip , <br /> I <br /> '41 / 441 b. ? 0/z3 <br /> Installation Company Name and Contact Info: . <br /> iCrn <br /> 1/1/1 1, <br /> Date Backwater Prevention device(BWD)was installed: 0:te this form was completed: i 4727'19 1 <br /> Installation Property Own r Name and Cori ct Info: 11 VU) , DAT/ As. <br /> Property Address: , ()U$ C1L3 <br /> Pre-Installatiort Inspection Checklist; <br /> All items must be checked Yes'111 order fora 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?Eg4s 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?flies 0 No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?[gle; 0 No <br /> Site inspection Checklist: <br /> Al!items must be checked Yes'befom inspection is considered comp! 8t , <br /> I il yl ey <br /> Was side sewer TVinspected from building to sewer main? es ED No Condition: t 20.-r 6-1.-- 4,— <br /> Does side.side sewer have at least 1%siope from the building to sewer main? lareS121 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? 111,x4r113 No <br /> Have all property storm drainage connections to the side sewer been identified and located? rci•Y‘s 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.): dt., <br /> A 40" <br /> Where was thedevice 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: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? RP efl-Ei No Comments: <br /> Does 13WD positioning,meets minimum slope requirement of>1%? Ill-Yes-1D No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? rarer 0 No <br /> Is BWD locked into the proper position and 4 . screw tightened? El...Yer--0 No <br /> .. . <br /> • <br /> Circle the BWD cover:irrigation coy-r(landscape .rea /tra'r, load bearing cover(drive surface)t access hatch(budding) <br /> ___ <br /> . <br /> Was property miner shown th- 0-: . a i e ins a led BIND? UALIW- No Comments: <br /> 4001 <br /> Property Owner's Signet - 46, , Date: I <br /> Installer's Signature: tralli Date: <br /> _ ....------- <br /> (..., <br /> Revision:2 1 Friday,September 12,2014 <br />