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I <br /> � <br /> � <br /> ,. �3A�P�UUr��'�� 6���V�6VT'@t�R9 ��V9CE FIN,AL : <br /> `�- ,T 9�1�`�'A�.LA'TB�t� �t��C14Ll�T � <br /> Installation Company Name and CoMacf In(o: M���'` I���w+��� ��y y� S� 7�,U -X 3�c <br /> a' <br /> Date �ackwater Prevenlion device(BWD)vdas insl;lled:� �r _Dale Ihis fnrm v+as r,ompleted� �O'.?"i1� <br /> Instaliation Property Owner IJame and Contact Irno: �r � ��. �'�"� ( �o � j S?� �3.�'� � <br /> Property Atldress: � 3� � ��,��._� ��--c ----- ---- ---- --- � <br /> i <br /> i're•Installation Inspection Checklist: <br /> Fl ff ifems must he checked`Yes'in order for a QWD to be consldered/or installation <br /> Is Ihere a basemenl or level oi Ihe house lhat is at or ne�r assumed sewer main elevation7 ,�Yes ❑ No <br /> i <br /> Are Ihere fi�ures in fhe house local�d below the upstream sevrer manhole rim elevation? (k�Yes ❑tdo <br /> Is the side sewer currently UNPROTECTE�trom se�ver backups(does nol have a B�ND insialled)7�1'es [� No <br /> Site Inspeclion Checkiist: � <br /> i <br /> All ilems must be checkeo 1'es'be�ore inspecfion rs considered complele � <br /> Was sltle sewer N inspected(rom building to sewer main7 �]Yes [] �b Condition �-���� it '1�� � <br /> Does side sewer have at least 1% slope from tho building to sewer main? �'(Yes ❑No Describe:��_.__ <br /> Have all building sewer drain connections lo Ihe side sev;er been identified and located� �Yes (� IJo ' <br /> Have all property storm Arainage conneclions lo ihe side sewer been identified and Iocaled'7 [�'es U No <br /> Has properly been evalualed for drainage deficiencies vrifh lindings communicated to property rnvner? �Yes n Ido <br /> Installation Details: <br /> 1h'hat lype and prand of�WD v�as inslalled at this si(e(Glean Check�WV, Grinder pump, etc.) ��.^�1r� ___ i <br /> INhere�vas Uio device installetl(general descriptian, atiach map)7 (s tc_�� � 5 �� � ��ti�-� _ <br /> lNas lheie any nihor sr.�v�r or storm drain�ye work completed in ncon/juncfion wi(h Ihe 13VJD woik? Ih so pina�e desr,ribr:_ � <br /> -- - -_ _ - � � <br /> Insfailation Cher.klist: { <br /> !ue ell downspouls and site drainage Aisconnecled irom upstream of fhr, 8WD"? �Yes U No Commr.nts:______ , <br /> Unes RWD posilinning meel:minimum slope requirement of>1°�a? (�Yes n No Comm^nfs:__ _ � <br /> C2n BVJD be pulled oul for inspeclion and mainfenance after loosening thumb screv�?�Xes-�No � <br /> Is []WD locked inlo the proper posilion and Ihumb serr,�v liyhlened? (�`Fes �No � <br /> Circlo ihe BWD cover: irrigation covei(landscape arr,a)I traffic lo�d hearin�r,over(drive sur�ace)/access halch(6uilding) ��/� <br /> INas property owner shown Uie lor:ahon oi Ihe inslalled [�WD7 [�J Yes �I tQo Commenis: ___ ___ ___ ' <br /> i <br /> PrnprRy OvmoYs Signature Date� , <br /> �.._ .. � <br /> fnslaller's Signatura _�� /'L________ _ Datr.;�n _1 /S' ` ; <br /> � <br /> Revision 2 1 Monday,;eptemher 1S,2014 <br />