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i <br /> I <br /> �ACB(VVA�'fER �ff��V(�P�`P9�N ��VBC� �GNA� <br /> @NSYA�LE�►T90N ��9�CK�.9�T <br /> Installation Com an Name and Contacl info �� � <br /> a Y = ,!'�' � LN,'/�/. L LC <br /> Oste Backwater PreveNion device (BWD)was installed:�� Ihis form was completed: - <br /> ,Insiallalion Property Ovmer Name and Conlact Info: h-�o/a��q �� I <br /> PropertyAddress: /S� � /��,�� �¢��? _ E de r�f � (�/✓¢ ga.�o ( <br /> Pre•Installalion Inspection Checklist: � <br /> ,UI items musl be checked'Yes'in order lor a BWD to be considered lor ins�allation � <br /> I; there a basement or level of Ihe house Ihat is al or near assumed sewer main e�evatior?� Yes ❑No � <br /> Are there fixlures In the house located below Ihe upstream sewer manhole rim elevation�,� Yes ❑ No I <br /> Is ihe side sewer curronlly UNPR07ECTED��om szvrer bac�ups (does not have a BWD installedl? � Yes ❑No <br /> Site Inspectio�Checklist: I <br /> All lfems musf be checked"Ye s'be(ore rnspecfion is considered complete � <br /> Was side sewer N inspected from building lo sewer rain? �Yes ❑No Conditlon: i <br /> Does side sewer have at least 1% slope from the buildin to sewer main? ± <br /> g (�Yes ❑No Describe: � <br /> Have all buliding sewer drain conneclions to Ihe side sewer been ident�fie�i and localed7 �Yes ❑ No <br /> Nave all property slorm drainage connections lo the side sewer been ide;iNfied and located? [�,Yes ❑No � <br /> Has property been evaluated lor drainage deficienci:s wilh findings �ommunicaled to pwpeAy owner? [�Yes ❑ No i <br /> Installation Details: ' <br /> What type and brand o18WD was installed at this si�e(Clean Check BWV, Grinder pump.etc.0 C�eAv� e���tiL I <br /> Where was the device installed(general description,aUach map)? ,�t,��� '� 1��v S � � <br /> I <br /> Was there any other sewer or slorm drainage work compleled in conjunction with the BWD work7 Is so please descnbe: ' <br /> _ <br /> v�D — I <br /> inslallaHon Checklist: � <br /> Are all downspouts and siie drainage disconnected pom upstream of the BWD? �Yes ❑ No Commenis � <br /> Daes BWD positioning meels mirnmum slope requirement of >1%? �Yes ❑ No Comments: � <br /> Can BWD be pulied out for mspection and mamtenance after loosening Ihumb screw? �.Yes ❑ No ; <br /> Is BVJD locked into Ihe proper position a (humb screw lightened7 .�Yes ❑ No I <br /> C�rcle Ihe BWD covec irrigalion cov r(landscap�a��traKc load bearing cover(drive surface)1 access halch(building) I <br /> Was property owner shown Ihe location of Ihe mstalled BWD? �Yes ❑No Comments _ 4 <br /> Property Ovmer's Sigaature: U ,;.��;,.� D2fC. .3�/3(/ S� � <br /> Installer'sSignalure: �.��� . Q1�.� Date: Z! �7�i5� � <br /> � <br /> Revision: 2 1 Friday, September 12, 2014 � <br /> I <br />