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��.�6�VlG0�� �� ���V�6�i9��9 ��V6�;� Fii�/�L <br />B�9�Tr���,�T'90N CF9���L�i��' <br />InstallationCompanyNameandContactlnfo: �'�JP.f� ���r,��.�� �1'aS fl�U f�36c:� <br />Date Backwater Preueniion device (BWD) ovas inslalled: G"�`-�� � U Date lhis form vaas completed:_ 6-�%u 7 S~ <br />Inslallaiion Properry O�a�ner Name and Contact Info: � l��v� Cress n� �I,� S 3�.� l�i 7 7 <br />PropertyAtldress: �f� �+`� p�vt- <br />Pre•Instailation Inspection Checklls� <br />All items must 6e checked 'Yes' in orzfer (or a BtND fo be considered for installation <br />Is there a basemenl or level of lhe house Ihat is at or near assumc.i se�ver main elevation? � Yes ❑ �o <br />Are there fixtures in the house locatetl belov.� fhe upsheam seH�er manhole rim elevation?� Yes ❑ No <br />Is ih� sida sevrer currently UNPROTECTED irom sev:er backups (does not hava a BWD installed)7 �] Yes ❑ No <br />Si(e Inspection Checkiist; <br />/!II ifoms must be checked'Yes' beiore inspection is conslderad complete /1� <br />liJas side sev:er TV inspecto� irom building fo sewer main7 � Yes ❑ No Condition: l�2 d�D'4^ `b ���% <br />Does side ser�er have at least 1% slope from the buitding fo sev�er main? �Yes ❑ �o Describe: <br />Have all huilding se�aer tlrain conneciions to Ihe side soe�er haen identined and locatod? � Yee ❑ No <br />Have all properiy slorm dralnage connections to lhe side s�wer Ceen identi�ed and located7 �'j Yes ❑ ��o <br />Has property heen evalualed for drz�nage deficiencies with 6ndings communicated to prope�iy owner? � Yes ❑ 140 <br />Insfallation Details: <br />(�o�� Cr-vL <br />INhat type and brand of BWD was installEJ at this sile (Clean Check BVJV, Gri;ider pump, elc.): __ <<r.�'�"'� <br />VVhere v�as the device inslailed (general description, ariach map)? (��.��n�c��" I.� c�'�-� �/-'/��1 Cr-✓L <br />� q, i. f 1�- - c� i... <br />Was Ihere any other s�t:�er or srorm dr� ge wnrk compteted in eomunclion with Ih? [iWD �n�ork? is co please descrlbe: _ <br />-- ---- ��----- - — <br />Installation Checldis4: <br />Nre all dovanspouls and siie drainage disconnecfed irom upstream of the DWD? �Yes ❑ Ro Commenls: <br />Ooes BUJD pnsitioning meels minimum slope requirement of >1%? � Ye� ❑ No Comments: <br />Can BVJD be pulled oul for inspection and mointenance afler loosening thumb screvl�-Yss-[] �o <br />Is DVJD Iocked into the proner posilion and thumb screvi tighfened?_ []�'es-{] No <br />Cirde the eV�U r,over. irrigaGon wver (landscape area)1 tra(fir. load bearing cover (drive suriace)/ access hatch (building} <br />\Nas property owner shoem the location of the installed BWD'? �(Yes ❑ Plo Comments <br />Propedy Ownor's SigaaWre: Date: <br />Installer's Signature: _ �� �z - - - Date: � � � `� - � S <br />Rr.vision: 2 1 Mnnday, September 15, 201� <br />