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+` d . 1 " " ' . �, [ <br />r► <br />l > 1 .,;. <br />�.��[�"i �GZi'� � � ��"�""i �-' `�"" ��+�� �C-& ���'�, � �..,�- <br />Instal[ation Company Name and Gontact <br />Data Backwater Prevention device (BWa} was installed: <br />installation Property Owner Name and Contact lnfo: <br />ProperEy Address: <br />Pre-Installatian Inspecfion Checkli <br />Date ihis form was <br />AII items musf be checked `Yes' in order for a BWD fo be considered for rnsfallafion <br />fs there a basement ar level of the hfluse that is at or near assumed sewer main elevation? �'es ❑ No <br />Are there fixtures in the (�ouse loeafed below the upstream sewer manhole rim elevation? � Yes ❑ Na <br />[s the side sewer currently UNPROTECT�D from sewer back�p� (does not have a BUUD instailed}� [�'es ❑ No <br />Site lnspection Checklist: <br />All iiems must be checked `Yes�' hefore inspecfion as considerea� camptete <br />Vi!as side sewer TV inspecied from building �o sewer main� (�Yes ❑ NQ Condition: �C` � <br />t <br />Does side sewer have at least 1% slope from the buiiding to sewer main? �l'es ❑ N� Describe: <br />Have alf buifd'tng sewer drain connections to tE�e side sewer been identified and located? [�Yes ❑ No <br />Have a!i prop�rty storm drainage �onneetions ta the side sewer been identifietl and located? �Yes � No <br />Has property been evaluafied for drainage deficiencies wifh findings communicated to property awner? �Yes ❑ No <br />Installatian Details: <br />What type and brand of BWD was installed at this site (Gfean Check SWV, Grinder pump, efc.): � ��� <br />Where was the device insta(led (general descripfion, attach map)? ��'l� ��� <br />Was there any other sewer or storrn drainage work completed in conjunction with the BWD work? Is so p(ease describe: _ <br />���o <br />(nstallatian Checklist: <br />Are all downspauts an� site dtainage tliscannected frorn upstream af the BV11D? �es [] �Ia Gomrnents: <br />Doe§ BWD positiorting meets minimum slope requiremerit of >� %o? �Yes ❑ No Comments: <br />Can BWD be pulled �ut for ir�spection and maintenance after loosening thum� screw� �Yes ❑ Na <br />Is 61ND locked into the prope� positic�n and thumb screv� tightened? ��t'es ❑ Na <br />Circle the BWD cover, rrigation cove ndscape area)1 traffic Ioad bearing cover �drive surface} / access hatch (building) <br />Was property own�r si�own fhe locatian af the installe� BWD? �'�'es ❑ No Gomments: . <br />(�`�1��.� � �� �: �( �, (>,. <br />Prdperty Owner's S�gnature,�; <br />Instailer's Signatu <br />Date;,� j�f �- �/'� <br />Dafe: ,� "�- /�.. `" /,�-' <br />Revision: 2 ""v 1 Friday, September 12, 2014 <br />