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�3A�KU1�'Al'E� i�R�V�Bii�9�f� �EVIC� FIR9i4L <br />E€�ST�4�LATYON �FiE�14L.IS�" <br />�r� c«n �r� U�r �� sc.� ��r, � �c <br />Installalion Company Name and Contact Info:: <br />Date Backv�ater Prevenlion device (BWD) was installed: �,� 5�.G,S _ Date this torm was completetl: :h l.� �.�,_ <br />Inslallalio i Property O�+�ner Name and Contact Info: M A �"1 11! i� 1 lTZ- l.� �� '� ��� '���� 7`� <br />Properiy tiddress: _gC)i � u �g`I P. Ui: F_� �-� �, nl h /�i�� �/ _ <br />Pre•Instailation Inspection Checkiist: <br />All items must be checked 'Yes' in order (a a BIh�D lo be censidered for inslallalion <br />Is there a basemenl or level oi the house Ihal is at or near assumed sea�er main elevation? � Yes ❑ No <br />Are there fixtures in lhe house located below the upsiream sewer manhole rim elevation7 � Yes � No <br />Is Ihe side sewer currently UNPROTECTED irom sewer backups (does not have a BWD install2d)7 Uc] Yes ❑ No <br />Site Inspection Checklist: <br />All ifems must he checked'Ves' 6e%re inspection is considered complete <br />VJas side sewer TV inspected irom t�uilding to se�ver main? � Yes ❑ �o Condition: ��,��___ <br />Does side sewer have atleast 190 slope from the builtling to sewer main? � Yes ❑ No Describe: <br />Have ail buitding sewer drain conneclions to Ihe side se�ver been identified and localed? � Yes ❑ No <br />Have all property storm drainage connections lo the side sewer been identifed and localed? � Yes ❑ No <br />Has ^roperly been evaluated for drainage deficiencios �vifh findings communicated to property ov+ner? X❑ Yes ❑ No <br />Installation Details: /� <br />VJhal .,pe and brand of f3WD was inslalled al this sile (Clean Check BVJV, Grinder pump, el j}: �1' :{zl ��l��atl <br />lNhere was Ihe device installed (general description, atlach map)? 4`.'•C� (_Y�Co�c.Oc_�S..�jL.� a i� <br />lNas therc any other see�er or storm drainage �+�ork completed in conjunction wilh lhe DWD �vork? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnecled from upstream of the DWD? � Yes ❑ No Commenls: <br />Does BWD positioning meets minimum siope requirement of >1%7 [�Yes ❑ No Comments: <br />Can BWD be pulled out for inspeclion and mainlenance afler loosening ihumb ssrew? � Yes ❑ No <br />Is BWD locked into the pr� r�osili�n apd thumb scre�v lightened? `�}Yes ❑ No <br />Cirde the BWD coverj'�fn alion cover dscape area) l lraflic load bearing cover (drive surtace) I access hatch (building) <br />14�as properly owner sTmWn lhe location o( the insfalled BWD? �Yes�j No Commenls: <br />�,� �� <br />Property Owners Signa(ure: <br />Instalier's Signalure: <br />Revision: 2 <br />/( <br />r <br />Date: 03 — D,� — % ,� <br />Dat : � <br />Kriday, September 12, 2014 <br />