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I <br /> �p,C�We�T'EF� F��E�✓�Pl�flOf� DE!/ICE F@�lAL. I <br /> iPl��"d�L.L���BOY� �FiECK�iST I <br /> ; <br /> �'u�-c eczr� �,��F+��c-� � �,de S��:i�. L�_c_ I <br /> Installalior� CompanyNameandContactlnfo:J�•��e � .Nl `7`�)'"�'��5����ii�^li���L�''��'";� � <br /> Date Backwafer Prevention device(BUJD)was insfalled:�S Date this form ivas completed: v! � � <br /> i <br /> Inslallalion Property Owner Name and Contact info:� '/1� �i[''�CM. {'d�� ' d'd.� — (��,r1 j <br /> Property Address:s��-D I ,{/1 i.,t � �,���'��' ��.� Cl' � <br /> Fre•Installation Inspection Checklist: `• <br /> All ifems musl be ciiecked 'Yes'in order for a BWD to be r.onsidered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevaticn7 [�Yes ❑ No � <br /> � <br /> Are there fixh�res in ihe house localed below the upstream sewer manhole rim elevation?�Yes ❑ No ; <br /> Is fhe side sewer currenfly UNPROTECTED from sewer backups (tloes not have a BWD installed)? �Yes ❑ No i <br /> � <br /> � <br /> Siie Inspection Checkiist: ' <br /> ;. <br /> Nl items must be checked'Yes'before inspectron is considered complete � <br /> 4Nas side sewer TV inspectetl from building to sewer main? � Yes ❑ No Condition:��z P� j <br /> Does side sewer have at least 1%slope from the building to sev�er main? (�Yes � No Describe:_ � <br /> Ha��e all builtling seveer drain connections to Ihe side sev�er heen identified and located? �Yes ❑No � <br /> i <br /> Have all property storm drainage connections to the slde se�ver been identified and locatetl? �Yes ❑ No ;- <br /> Has property been evalualed for drainage de(iciencies wilh findings communicated�o properl;�owner? �Yes ❑ No ; <br /> Installation Details: ! <br /> What type and brand of BWD was inslalled at ihis site (Clean Check BWV, Grinder pump, etc.): - - � -; <br /> Where was ihe device inslalled (generai descriplion, atlach map)? ���['�Q�� QG (��l�.c1.-� ; <br /> i <br /> ; <br /> Was there any other sewer or storm drainaye�vork cornpleted in conjunction with lhe EiWD work? Is so piease describe:_ ; <br /> �.`lfS1�__ '• <br /> Instailation Checklist: j <br /> Are all downspouls and sife tlrainagc disconrected from upsiream oi ihe E3WD? �h'es ❑ No Commenfs: _ <br /> Does BWD posilioning rnee�s minimum slope requirement of>1%? [��Yes ❑ No Commenls: ' <br /> Can BN1D he pulled onf(or inspection antl mainlenance afler loosening thumb screw? .�'es ❑ No � <br /> Is BWD locked into the pru�posjtiotind ihumb screlv lightenetl? �Yes ❑ No � i <br /> Circle the�WD cove(�� Irngation cove�{ao�idscape area)/traflic load bearing cover (cirive surface)f access hatch(building) � <br /> Was property owner s'howirlhe locafion of the installed BVUD? �l"es ❑ No Commenls: ! <br /> I <br /> Properiy Ovvnar's Signature: / � "(� �� v �/l�{ l31�—�-� Dale: J/" J � > � � <br /> Installer's Signalur r �� ��c,' - ' Datc: S•_���_(_S- ; <br /> Revision:?_ 1 Friday,Septembcr 12, 20]A � <br />