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� �A��lPJ��E� �RE�/E�IT6o�V ��vlc� FIl��9L <br />� Ii�4STf�L.L�I�TO�fE! CFIE�K�..9S� <br />�ru.ri cun �/.+ � G�� � �de 5c-��1 t- Lc <br />Installation Company Name and Cor,tac� Info:J��L <br />Date Back�vater Preveniion device (�UJD) �vas insta <br />InslaCation Property Owner Name and Contact Info: <br />Property Address: �� � ' - �L <br />�ate ihis form �vas completed:s`F=„t"-`— <br />Pre-Installation Inspection Checklist: <br />A!1 items must be checl<ed 'Yes' in order for a BWD to 6e consioered for installation <br />Is there a basement or levei of tiie house that is at cr near assumed sewer main elevation? � Yes ❑ No <br />Are ihere fixtures in the house loeated belo�v the upstream sewer manhole rim elevation? (�Yes ❑ No <br />Is ihe side seu�er currenUy UNPROTECTED from sewer backups (does not have a BWD installed)?�Yes ❑ No <br />Site Inspeetion Checklist: <br />AN item� must be crecked'Yes' before inspection is considered ccmplete ���� <br />�.Nas side sewer N inspecled from huilding to setver main? �Yes ❑ No Condition: <br />Does side sevrer have �t least 1% slope irom ihe building to sewer main? �Yes ❑ No Descrihe: <br />Have al! building sewer drafn connections to the side setver been identi6ed and located? [�'es ❑ No <br />t <br />Have all property storm drainage cnnneclions to the side sewer been identified and located7 �Yes ❑ No <br />Has property been evaluated for drainage defic�encies avith findings communicated to properfy ovmer? �Yes ❑ No <br />Installation Details: <br />VJhat type and brand of BWD v�as installed at this site (Clean Check BWN, Grinder pump, etc.p - '��I � '_ <br />VJL•ere was the device ins'�Iled (yeneral description, a�taeh map)? �� ,' �L�C�.i�C �l.t �'�' <br />1Nas ihere any other sev�er or sbrm drainage �vork completed in cnnjunciion �vith the BVJD wor'�c? Is so please describe: <br />Installatlon Checklist: <br />Are all downspouts and sile drainage disconnected from up� 'eam oi the BUVD7 �'k Yes ❑ No Commenis: <br />Does BWD posilioning meels minimum slope requirement of >1 %? � Yes ❑ No Comments: <br />Can BWD be puiled out (or inspection and maintenance afler loosening thumb screw? �'Yes ❑ No <br />Is BWD locked into ihe proper posilion and lhumb screw tighlened?�Yes ❑ No <br />Circle the BWD co��e . irrigalio�r-�Zandscape area)1 traftie load bearing cover (drive surface) I access hatch (building) <br />Was preperry owner sho�vn the localion of the installed BWD? �Yes ❑�o Comments: <br />n� � <br />Property Ovmer's Signaluie: I� � ���: � ,. Date: ,� <br />Installer's Signature: Date: J�.(J <br />Revision: 2 1 Friday, September 12, 2014 <br />