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�dl��A�'��8 ���V��°���6� ��i/@�� FifVAI, <br />BN�'T����'�@��9 �e�9�CCKC�9��' <br />�m.�.s..�...... <br />Installation Compeny Name and Contact info: MUCf� �lk�., �;;� y �{ a f 7�U <br />Date Backwater Preveniion device (BU��D) was installed: 7`vt7—(S'� Date this form was completed; �"��—� � <br />Insfallaiion Properly owner Name and Contact Info: r'1� ��- St�t.� ,� �I !"� 3N S'— 7vS-7 <br />Property Address: N D 1 i I-�: (, S�-; <br />Pre•Installation lnspectlon Checklisf: � <br />All ilems must be checked 'Yes' in arcier (or a BWD to 6e considered for ir,stallation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? � Yes ❑ No <br />Are there fi�ures in the house locatetl below the upstream sewer manhole rim elevation7 0 Yes ❑ No <br />is ihe side sa�ver currently UNPROTECTED irom sewer backups (does not liave a BWD insielled)7 (� Yes ❑ No <br />Site Inspeciion Checklist: <br />A!1 items must 6e checked'Yes' beiore inspection ]s consideied complete <br />Was side sewer N inspected irom building to sevaer main7 �'Yes ❑(Vo Condition: C—uil Z <br />Does side sewer have at leasf 1% slope from the building to sewer main? Q Yes ❑ No Describe: <br />Have all 6uilding se;ver drain connections to the side sewer been iden5ried and losated? �Yes ❑ No <br />Have all properry storm drainage connectlons io the side se�ver been identifled and located? � Yes ❑ No <br />Has property heen evaluated for drainage deficiencies with findings communicated io properiy ownerl � Yes ❑ hlo <br />Ins(allation Details: <br />1Nhat type and brand of BWD was insfalled at this site (Clean Check BWV, Grinder pump, stc.): � c k� (' �w� (r�.�,,C <br />Where was the device instelled (general description, aliar,h map)7 h4>e n�.,.i' ti„ y/�r„ �-c <br />� ...__�.m <br />Was there any other se�ver or storm drainage work completed in conjunclion �vdh the BWD work? is so please doscdbo: <br />— ti/A <br />Insfallafion Checiclis4: <br />Are all downspouts and site drainage disconnecled irom upstream of the BWD? �Yes ❑ No Comments: <br />Does BWD pnsitioning meets minimum slope requirement of >1°l0? �(Yes ❑ No Comments; <br />Can BWD be puiled oul tor Inspecllon and mainienance zfter loosening thumb sere��v? �o <br />Is 8W0 locl<ed into the proper position and thumb screw tightened? No <br />Circle the BWD cover: irriga6on cover (landscape area) / traKc load bearing cover (dri��e surtace) ! access hatch (buildingjN/A <br />Was property owner shown the IocaOon of the installed BWD7 � Yes ❑ No Comments <br />Property OwnePs Signature: Date: <br />Inslaller's Signature: _^Wl ,/" Date; 7- � % �I� <br />Revision: 2 . 1 Monday, September 15, 2014 <br />