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8ACMIIJATER PRE&3ENT� ON riEvic ti FiNAL <br />Y <br />Installation Company Name and Contact Info: MJeh <br />Date Backwater Prevention rev <br />ice (BWD) was Installed:. - /_ t Date this form was completed: � � 6-1r Installation Property owner Name and Contact Info: �%. c Se vm n <br />Property Address: n2 1 / 7 I (e � S!- �I 2 f' y �z y t 3 <br />Pre -Installation Inspection Checklist: <br />All Items must be checked Yes' fn order for a BWD to be considered forinstallaUon <br />Is there abasement or level of the house that is at or near assumed sewer main elevation? (3"Yes ❑ No <br />Are there fixtures In the house located below the upstream sewer manhole rim elevation? ® yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? © yes <br />Sitelnspection Checklist: <br />■ <br />All Items must be checked Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? ConcrY� c <br />Does side sewer have at least 1% slope from the building to sew r main? ❑ No Condifien: b'a�a�., I r s �.-,, . <br />Have all building sewer drain connections to the side sewer been identified anted locatedes ? No Describe: <br />Have all property storm drainage connections tifi <br />o the side sewer been idented and located? Yes ❑ No <br />ff <br />Has prapetiy been evaluated for drainage deficiencies with findings communicated to property ovmer? [ yes ❑ !do <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWtt, Grinder pump, etc.): C`^� � t � rzu. GAL <br />Where was the device installed (general description, attach map)? we , . d —r--- <br />Was there any other salver or storm <br />work completed in conjunction with the BWD work? Is so please describe: <br />Installation Cliecl:llst: <br />Area[[ downspouts and site drainage disconnected from upstream of the BWD? Eyes ❑ No Comments: <br />Does BIND positioning meets minimum slope requirement of>1%? Byes ❑ No Commenis: <br />Can BWD be pulled out for Inspection and maintenance after loosening thumb screw? o <br />Is BWD locked into the proper position and thumb screw tightened? , o <br />Circle the BWD cover irrigation cover (landscape area) / traffic load bearing cover (drive surface) I access hatch (building)4 <br />Was property owner shown the location of the installed BWD? Oyes ❑ No Comments: <br />Property Owner's Signature: <br />Installer's Signature: �---- <br />Date: <br />Date: 8-- a 6 - I r <br />Revision: 2 1 Monday, September 15, 2014 <br />