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. . � -: . • �; ' ;i, � <br />. �� � � <br />��y�—;'��� ��;��'� <br />� - �-� `� "� <br />Installatlon Company Name and Cantact In#o:.��=� �~�-�' .,� ���` ��`��-''�����' <br />bate this form <br />Date Backwater Prevention device (Bt�1D) was installed t _ . _ _� � � � .. � .� ..�I �- <br />Instaifation Property Owner Name and Contact info: <br />PrapertY Address: <br />� <br />;�-,�-`� �;— �...�..� <br />��t�+c�c�:.� <br />. <br />Pre-installation Inspection Checklist: <br />A!I items must be checked 'Yes' in order for a BWD t0 ear ass �med sewer ma nt1elevation? �eS ❑�° <br />is there a basement ar kevef of the house that �s at or n <br />Are there fixtures is� the house located beiow the upstream sewer manhole rim elevation?l��' I�a �� Yes ❑ Nn <br />Is the side sewer currently UNPR�TECTED from sewer backups (does not have a BWD }-�' <br />Site lnspection C�ecklist: <br />pf1 items must be checked 'Yes' before inspection rs considered comprete ���� <br />Was side sewer TV inspected f�om building to sewe� main? (�Yes ❑ No Condition�� Describe: <br />Daes side sewer have at least 1% slope from the buiiding to sewer main? a� ocated�? Yes ❑ No <br />Have al1 bui�ding sewer drain connections io the side sewer been �dent�fied � <br />Nave a11 prope�ty storm drainage connections to the side sewer been identified and iocated? �' �� � Yes ❑�o <br />been eva{uated for drainage deficiencies with findings cammunicated to properiy � <br />Has properry � <br />Installation D�tails: , ` �� <br />Whafi t e and brand of BWD was instakled at this site (Clean Check BWV, Grinder p�mP, etc.): ��� __,l i <br />YP �� <br />Where was the device instai{ed (general description, atfacn map)? r <br />Was there an ather sewer or storm drainage work completetl in canjunction with the BrND work? ls so please describe: � <br />y I.�..u`�Y� <br />InStatiatian Gheck�ist: <br />Are ail dawnspouts and site drainage disconnected from upstream of the BWD? ��SC �m ntsGomments: `�____. <br />Does SWD positioning meets minimum slope requirement af l�aseni� thumb s�creW`? Y�es ❑ No <br />Can 8WD be pul�ed outfor inspection and maintenance after 9 � <br />is BWD locked into the proper,po.sition and thumb screw tightened? �eS ❑�° <br />Circle the �W4 cove�: �' rigatian caver�andscape area)1 tra�ic load bearing cover (drive surface) I access hatch (building) <br />the ation of the insYalied BWD? ��fes ❑ No Comm�nts: <br />Was property owner shown � <br />Date: � � � � <br />Property Owner's Signature� ,_ � [� �/,� <br />� ' pate: 1 <br />Installer's Signature; <br />1 Friday, September 12, 2014 <br />Revisian: 2 . <br />