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�A�P,�A�'�6� ���@��8��9�N D�liQC� �6�V�ifl� <br />@��"�f�.@�f��A�'@�� ������5�`� <br />InslallationCompanyNameandContactlnto: ���Cf� ��tiM���� ��af 7�U $�6c:� <br />Dafe Backwater Prevenlion device (BWD) was installed: -1 �-�S� Date ihis fortn was compleied: 6-` ��-f f <br />Inslallaiion Property Owner i�ame antl Contact Info: ��c,�n.Q �(� ti f�k� «`I2f`� 33y St z� <br />Property Atldress: �( I�9 C d ��iV �� <br />pre•Instaltation Inspecfion Chocklist: <br />All items must be cfiecked'Yes' in order for a 814�D lo be considered forinslellafion <br />Is there a basement or level oi the house lhat Is at or near assumed sewer main elevationl �Yes ❑ No <br />Are lhere (ixtures in ihe house Ierated below Ihe upstream setiver manhole rim elevation? �Yes ❑ No <br />Is the sitle se�ver currently UNPROTEC7ED from sevaer �ackups (does not have a BWD insialled)7 ��Yes ❑ No <br />Sfie inspoction Checklist; <br />AI! iferns must be checked'Yes' before inspection is r.onsidered complete <br />Was side sewer N inspecied irom building lo sev�er main7 �Yes ❑ No Condition: ����K-'�- �,�`-`� �w �- <br />Does side sewer have at least 190 slope irom lhe building io se�ver main7 Q�'es ❑ No Descri6e: <br />7— <br />Have all buildiny se�ver drain conneclions to the side seveer been identined and located? (�'Yes ❑ No <br />Ha��e all property storm drainage connections to the side sewer been identified and locatetl? �1 Yes ❑ No <br />Has property been evaluated for drainage deficiencies �vilh findings communicated to property o��,�ner1 �"Yes ❑ No <br />Installation Defails: <br />�r�rhat type and brand of BWD H�as installed al this site (Clean Check BWV, Grinder pump, etc.): ���� � 1-�-'��� <br />V��here v�as lhe device inslalled (general description, atiar.h map)? ��� 5��'�- v� �`�'" �� ��^ _, <br />Was ihere any other,�ev���r or slorm tlrainage work compleled in conjunclion wiUi Ihe BWD workl Is so pleaso describe: _ <br />Installation Checldlst; �� S/��`��f `^� ' <br />Are all do�vnspouls and siie drainage disconnected from upstream of the BWD? ❑ Yes (� No Comments: ��,�ME�J°L � <br />Does BWD positioninc� meets minimum slope requiremenl of >1%? �Yes ❑ I�o Commenis: � <br />Can BWD be pulled out for inspeetion and mainlonance afler loosening Ihumh screva? �'Yes ❑ �o ! <br />Is BWD lor.ked into tho proper osition and thumb screw tightened? [�Yes ❑ t�o ' <br />Circle the RWD cover. ��ation cover antlscape area)1 trafiic load bearing r.over (drive sudace) / access hatch (buildingj � <br />Was properly owner sh��rt-lheiocation oi the inslaiied BWD? [i�;Yes ❑ No Commenis <br />Property O�vnePs Siqnature: Date: <br />Inslaller's Signature: �'T�f��� Dafe; ,�� `� � " � � <br />Revision: 7 1 Nonday, Septembe� 15, 2014 <br />