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�,� � <br />�j���i <br />r � �' �� �! `��� <br />�< ��% ��� <br />�� 3 �. �� � ��� <br />,., . , : ° ` ._, " , <br />i � <br />� ��'�'� ���� �' �� ��; � �`�� ���: :�� �- ��:.. <br />Installation Company Name and Contact Info�� �_�� '-. ,�; . ` ' = �' � . �:� ' ;` : a: ;; .. �._ _ �-� <br />Date Backwater Prevention device (B1ND) was instal(ed: �- ��—� �v _ Date this form was completed: �-��.� � <br />lnsta(lation Property Owner Name and Contact info: � ��r1 � ��� ' '�'�� �' � °���` <br />� '`�t Y��' 4 ���.Y�.. _�_ �.� � � <br />Property Address: ��L�`n� ,,,��Y �_---,— <br />Pre-Installativn Inspection CheckEist. <br />A!! items musf be checked `Yes' in order for a B WD fa be consfdered for fnsiallation <br />Is there a basement or level of the house that is at or near assun�ed sewer main elevation? � Yes ❑ No <br />Are there fixtures in the house located befow the upstream sewer manho(e rim elevation? � Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (tlaes not have a BWD installetl)? �] Yes <br />■ • <br />Si�e lnspectian Check(ist: <br />Alf ltems musf be checked `Yes' before inspecfton is consfdered eomple�� � <br />Was side sewer TU inspec#ed from building to sewer main? �`!es ❑ Nfl �ondition: �t`fU� <br />Does side sewer have at least 1% slope from the buiiding t� sewer main? [�'Yes ❑ No Describe: <br />HavE ali bui3ding sewer tlrain connectians to the side sewer been iden#ified antl located? [�`es ❑ No <br />Nave alf pr4perty storm draFnage connections to the side sewer been identified and locatetl? [�Yes ❑ No <br />Has praperiy been evaluated fior drainage defiiciencies with findings communicated �o praperfy owner? �Yes ❑ No <br />ln���liation Details: � <br />What type and brand of BWD was instailed at thfs site (Glean Check BWV, Grinder pump, etc,): '����� <br />Where was the device insta{led (general deseription, aitach map}? =�� . C•.��'_ ��..,,�5'� I��l.�.�" <br />Was there any ofher sewer ar st�rm drainage work completed i r� canj�nction with the BWD work? ls sa please describe; _ <br />lnsfa(la�ion Ghecklist: <br />Are alf downspouts and site tlrainage disconnected from �pstream o# the 81Nt�? e� <br />Do�s BUUD ositioning meets minimum slape requirement of>�°lo? [�es ' No <br />� No Gamments: <br />Comments: <br />P <br />Can BWD be pulled out for inspection antl maintensnce after lo4sening thumb screw?��'es ❑ Na <br />Is BWD locked into the pr�per-position� nd thumb screwtightened? �Yes ❑ No <br />Circle the 8WQ cove . irrigation covec I scape area} (traffic load bearing cover (drive surface) ! access hatch (building) <br />�`�" ed B1ND? Yes No Camments: <br />Was property owner shown the location o# the Enstall � ❑ <br />Property Owner's Signafure: <br />Insfa�ler's Signature: <br />Date: �--'��—ll.v <br />Date: :� �.�,.�`,�-Gf `°a <br />Revision: 2 ��`� � � Friday, September 12, 2014 <br />