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. ° � - - <br />.,.: j ,. , <br />� ; ��, ,a � <br />, �`' ; � ;� ' � <br />� . ; ; � <br />'`'� - _ ' -�; <br />Instal(ation Company �Iame and Contact Info: M � P./� <br />r' I y M �;, <br />� 7�t� ��6c:;� <br />Date Backwater Preven#ion device (BUUDj was instafie�: �� ��7 -� � U pate #his �orm was eompleied: �'�- 7��� <br />Ins#allation Property �wner Naine and Gontact fnfo: '�� �� S,G�.r�....���� <br />-- r <br />Proper�y Address: `� S r� r�tG d,,<—.�,� { t q�,.�. � o� �-7�� S c� f <br />Pre�instatla�ion lns�ec�ion Checiciist: <br />Afl item� musf be checked `Yes' rn orrler for a BWD to be consider�d far ins�alla#ion <br />Is the►�e a basement or level oi the house ihat is at or near assume� sewer main eEeuation? �( Yes ❑ No <br />Are fhere �xtures in the house lac�ted beEow the upstream sewer man�a[e rim elevation7 [� Yes ❑ i�lo <br />(s the side sewer currently UNPROTECi'ED fram �ewer backups (does not have a B11UD instailedj? � Yes ❑ Na <br />�ite Ins�e��ion Checktist; . <br />AfI ifem� musf be checked `Yes' before inspecfron is considererl complefe <br />Vtjas side sewer N inspected irom building to sevder main? �'Yes ❑�4o Condition: �iG� �- I7U L <br />Does side sewer have at leas# 1% slope fcom the buildi�g io sewer main? � Yes ❑ Na Describe: <br />FiaVe akl buifd�ng sewer drain conneciions to the side sewer been identiiied and locatad? � Yes ❑ No <br />Have a!I praperiy sfiarm drainage cannectians ia the side sewer been iden�i#ied and lacafed? k�Yes ❑ i�o <br />Has proper�y been evaluated for drainage defc�encies with� fndings communicated t� praperij+ owner? �Yes [� f�o <br />[�s�f(a�iort Defalls: <br />Whai type and brand of BWD was ins�alled at this site {Clean Check BVIIV, Grinde� pump, etc.): C! p� L 1..� � ir <br />Where was the device insfalIed (general descriptiQn, ai�ach map)? ��S_� ���'� a� ,� d�.--�-�. <br />Was ti�er� any other sewer ar storrn drainage work compieted in aonjunction with the BWD work? !s so piea�e describe: _ <br />./ll%��' - . <br />lnsfialfa�ian Ghecklisf: <br />Are ail dawnspauts and si�e drainage disconnected �rom upstream of the BWD? 'Q Yes ❑ No Camments: <br />Daes BWD positioning meeis minimum siope req�irement o# >�°Jo? �Yes ❑ No Commen�s: _ _ _ <br />Can Bt� be gulied o�.�t for inspection �nd mainienance after loosening thumb scre�r�? � Yes ❑�o <br />!s BVSf� (ockec� into ihe proper pnsition and thumb screw �ighfene�? ]k� Yes ❑ Nv . <br />Circle ti�e BWD cover• �rrigation cqve ndscape area) ! traf�ic load �e��ing caver (drive surface} I aacess hatch �buiiding) <br />Was properiy owner shown the lacafsan of'�e installed BWD? [�"Yes [] �o Comments: <br />Praperiy �wner's Signature. Data: �'� �" �` ( � <br />Insfalier's Signa�ure: ``��'�����----- Date: <br />Revisian: 2 1 Monday, 5eptember 15, Z014 <br />