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(4677' <br />SA6%NQ'7aATE.R PREVENTON DEViCF— NNAL <br />Installation Company Name and Contact Info: /iDPfr n/� f, <br />Date Backwater Prevention device (BVVD) eras installed: % — I — I r a f 7�U �6U <br />Installation Property Owner Name and Contact Into: 1-1, ' i I Date this form was compk ed: `1- I -1 S` <br />Property Address: ('7 0) v,-r I c t <br />Pro -installation Inspection Checklist: <br />All items must ba checked 'Yes' in order fare BWD lobe considered forinstallejon <br />Is'heI's a basement or level of the house that is at or near assumed sewer main elevation? R'Yes ❑ No <br />Are there fixtures in the house located belov.' the upstream server manhole rim elevation? Eyes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BVVD installed)? [2]S "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 main? 13 yes ❑ No Condition: C rc c'kr ,-t-Ir <br />Does side sewer have at least 1"ro slope from the building to salver main? Yes ❑ No Describe: <br />Have all building sewer drain connecbons to the side sewer been identified and located? Eyes []No <br />Have all properly storm drainage connecfons to the side Mar been identified and located? VYes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to propertyowner? ffYes [] No <br />Instailation Details: <br />What type and brand of BWD Was installed at this site (Clean Check BWV, Grinder pump, etc.): 2 C cnetc- % <br />When; was the device installed (general description, atiach map)? <br />Was there any other sewer or storm drainage Work completed in can <br />jun on with the BVJD vrork? Is so please describe: _ <br />installation Checklist: - <br />Are all downspouts and site drainage disconnected from upstream of the BWD? Ef Yes ❑ ,No Comments: <br />Does BWD positioning meets minimum slopo requirement of >1%? RfYes ❑ No Comments: <br />Can BWD be pulled out for lnspecitor. and maintenance after loosening thumb screw? F <br />Is BWD locked Into the proper pos!tion and thumb screw tightened? D-Yes�No <br />Circle the 8WD cove andscape area) I traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of the Installed 8WD? Yes I] No Comments: <br />Property Owner's Signature;_ Date: <br />Installer's Signature: �; � Date: <br />Revision: 2 1 Mnnday, September 15, 2014 <br />