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R o u S BRiI A � '� `/ <br />Installation Company Name and Contact Info: P�� ao�'�/6s•�%� 13 %tbso��s7cRna���kif G�n, <br />Date Backwater Preveniion device (BWD) �vas installed:Il"IB "�p/y Date this iorm was wmpleted: -�g-�d LL <br />Installation PropeRy Owner Nan�e and Contact !nfo: � R� M� /rJ <br />Property Address: <br />Pre•Installation Inspection Checklist: <br />AI! items musf 6e checked'Yes' in order for a 8WD to be considered for installation <br />Is there a basement or level of the house thal is at or near assumed sewer main e!evation7 �j Yes ❑ No <br />Are there fixtures in the house located 6elow the upstream sewer manhole rim elevation? � Yes ❑ No <br />is the side sewer currently UNPROTECTED from sev+er backups (does not have a BWD installed)7,�j Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' be(ore inspection is c.onsidered complete <br />Was side sewer N inspected irom building to sewer main? �] Yes ❑ No Condition: <br />Does side sewer have at least 1% slope from the building to sewer main? (�' Yes ❑ No Describe: <br />Have all building sewer tlrain connections to the side sewer been iden(iiied and located? f$I Yes ❑ No <br />Have all property storm drainage connections to the side sewer been idenlified and localed? � Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner7 � Yes ❑ No <br />Installation Details: KectdZS� <br />What type and brand ot BWD was insia!led at this site (Cir,an Check BWV, Grinder pump, etc.): (/� - c <br />� I T • • � <br />Where was the device instalied (general descripiion, atlach map)7 <br />Was there any other sevaer or storm drainage work compleled in conjunction �viih the BWD work? Is so please desctibe: � � <br />Installation Checklist: <br />Are all downspouts and site dreinage disconnected trom upstream of the BWD? Rj Yes ❑ No Comments: <br />Does dWD positioning meets minimum slope requirement of >i%? � Yes ❑ No Commenfs: kfoR� %��.N �% <br />Can BWD be pulled out for inspection and mainlenance afler loosening thumb scre��r1 � Yes ❑ No <br />Is BWD locked into the proper�ositio� n and thumb screw tightened? � Yes ❑ No <br />Circle the BWD cover irrigation cor (landscape are /1raHic load bearing cover (drive su�iace) I access hatch (building) <br />Wss property o�vner shown ihe location of the installed BIND? -� Yes ❑ No Comments: . <br />� <br />Property Owner's Signat r: Date: �l�/9�5� <br />Installer'sSignature: � l�h,(` Date:�,l l� r�D�� <br />Revision: 2 1 Monday, Septemher 15, 201A <br />