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Installation Company Name and Contact Info: Mocn I" 1r,14:,ny `( ate 7(,U 9-7( cb <br />Date Backwater Prevention device (BWD) was installed: Date this form was completed: <br />Installation Property Owner Name and Contact Info: Ly-��z <br />Property Address: J f'a <br />Pre -Installation Inspection Checklist: <br />All items must be checked'Yes' in order b;, a BWD to be considered fv installation <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? ©Yes ❑ No <br />Are there fixtures In the house located below the upstream server manhole rim elevation? © Yes ❑ No <br />Is the side sower currently UNPROTECTED from sewer backups (does not have a BIND installed)? R'Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes'before inspection is considered complete <br />Was side sewer TV inspected from building to sewer wain? ] Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? []Yes ❑ No Describe: <br />Have all building server drain connections to the side sewer been identified and located? []Yes ❑ No <br />Have all prope q, storm drainage connections to the side sewer been Identified and located? ❑ Yes ❑ No <br />Has propeliy been evaluated for drainage deficieni:ies with findings communicated to property owner? ❑ Yes []No <br />Installaton Details: <br />What b; pe and brand of BIND was installed at this site (Clean Check BWV. ' . finder pump, etc.): <br />Where was the device installed (general descdption, attach map)? _ _ <br />Was there any other server or storm drainage work completed in conjunction with the BWD work? is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? ❑ Yes ❑ No Comments: <br />Does RID positioning meets minimum slope requirement of 51 %? ❑ Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? ❑ Yes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? ❑ Yes ❑ No <br />Circle the BWD cover irrigation cover (landscape area) / traffic load bearing cover (ddve surface)! access hatch (building) <br />Was property owner shown the location of the Installed BWD? ❑ Yes ❑ No Comments: <br />Property Owner's Signature: �1 Date: <br />Installer's Signature: _ J���' --- Dale: 7-1- I s <br />Revision: 2 1 Monday, September 15, 2014 <br />