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�w { . .. .� r Y. r � � ( . <br />� � <br />� l , � <br />w���� <br />Installation Company Name and Contact Info: <br />�ate Backwater Prevention device (BW�} was insta1l�d: <br />Installatian Property Qwn�r Name and Con#act Infa: <br />Property Address: �� <br />� <br />r�llr����� <br />Da#e this farm was completed; ��` � r�`"�`f.� <br />Pr�•Instaltation Inspection Checklist: <br />AIJ items must be checked 'Yes' in order for a BWD t� be considered for installation <br />Is th�r� a basemen# or level of the house that is at or n�ar assumed sewer main el�vatinn? °�e�s ❑ No <br />Are khere fixtures in the house located b�low the upstream sewer manhole rim elevation? �es ❑ No <br />Is th� side sewer currently �1NPROTECTED fram s�wer backups (does nat have a BWD installed}'? ❑ No <br />Sit� Inspectic�n Checklist: <br />A!1 rf�ms musf be checked `Y�s' before inspecti�n is consid�red cornplete <br />Was �ide sewer TV inspected fram building kc� sew�r main? ; s❑ Na Condition: ��� t� -�l� `� °, <br />Daes side s�wer have at Ieast 1°la slope from the building to sewer �nain? �.-Y� ❑ No Describe: <br />Hav� �ll building sewer drain connections to the side sewer been id�ntifi�d and located? es ❑�o <br />Have a!I peaperty storm drainage connections to the side sewer been identified and iocated� �-�f°�s'"` ❑ No <br />Ha� p�operty been evaluated for drainage tleficiencies with findings communieated to prop�rty owne�? �s' ❑ Na <br />Instatlatian D��,ails; �` <br />What typ� and brand of BWO was installed at this site �Clean Check BWV, Grinder ump, �tc.�: -����°�-�� <br />Wh�re was the device install�d (general description, attach map)? � <br />Was there any ather sewer pr storm drainage work completed in conjunction with the BWD wark? Is so please descri�e: T <br />. ��'"�.�,�"� <br />InstalEati�n �h�ckli�t: <br />Areafi dawnspouts and site drainage disconnected from ups#ream a# fhe BiND? �es ❑ N� Gomments: <br />Does BWD positionin� m�eks minimum slope requirement of>1%? es ❑ NQ Gamment�: <br />Can BWD be pulled out for in�pection and mainte�ance aft�r ioosening thumb screvw� ��1�'es ❑ IUo <br />!s BWa l�ck�d inta the prQper pasitinn.a�t�t�.��►_� �cr�w tightened? [�]� ❑ Na <br />Circie #he BWQ cov�r: irrigativn <br />Was property owner shown the <br />Prop�rfy 4wner's <br />Install��'s Signature: <br />(landscape are '1 traf�c load b�aring cov�r (drive surface) l�ccess hatch (building} <br />a e instalied BWD? es � No Comments: <br />Date; �� <br />Date: ��'"-��`_`��. <br />Revision: 2 � 1 Friday, September 12, 2014 <br />