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�����/���� ���������� ������ �����... <br />� ����,�L��,���� ��������� <br />� i��`"1 ���;�� `�'.�9 i � �Y' �� i�� ����-�� � �.:.� <br />Installation Company Name and Contacf Info;�y ?�-'�� �i-r"�" ��C ���,�;�.:,�..�-�-��� 'i � � ��x'���-��-�='�� � <br />Date Sackwater Prevention device (BWD) was ii�stalled: � a��a Date this form was completed: v� <br />�' � �y � � ��' � � - � � <br />lnstallation Proparty �wner IVame and Cot�tact Info: � C.�<,c�t2_(r'L � 1�lt� � <br />Propetty Address: � ;7 � � ���-�' ��'�..i,'.�^ � '1�i 1�.�l.sz��� � ��` � <br />nre�inskallation lnspectian Checkiis�: <br />All items must be checked `Yes' in order for a BWp to be considerec! for installation <br />Is ihere a basemeni or {evef of the house ti�at is at ar near assumed sewer main elevaYion? �Yes ❑ No <br />Are there fixtures in the house located below the u�stream sewer manhofe rim elevation? j�Yes ❑ iVo� <br />Is fhe side sewer currenify UN�'ROTECTED from sewer backups (does not haue a BUUD instafled)? r��es ❑ Na <br />Sltie lnspection Checklist: <br />Rl1 items must be checked `Yes' before inspection is �onsidered compiete 3 { <br />Was side sewer TV inspected ;rom building ta sewer main'� [�'•Yes [] No Gondition: �`�`"�`�c� <br />poes side sewer have at least 1% slope from fhe buifding to sewer main? [��'es ❑ Na Describe; <br />Nave all buifdit►g sewer drain cot�nections to the side sewer been ident'sfied and lacated? ��fes ❑ No <br />Have all praperty stam drainage cor�nections tv the side sewer been identified and located7 [�fes ❑ No <br />Has praperty been evafuated for drainage de�icieneies with fEndings communicated to proper�y awne►? �es ❑ I�o <br />Ins%allaflon Defails: � <br />What Cype and brand of BWD was installed at this site {Glean Check BNN, Grinder pump, etc.): ���.� �=' <br />Where was fhe device instalied (general description, attach map}? � �= C� �� �� .���-�--T- <br />Was there any other sewer or storm drainage w�ork compiefed ln conjunction with the BWp wor#c? Is so please describe; ,_ <br />r <br />lnstaliatian Checkiist: � <br />Are alf downspouts and site drainage disconnected from upstream of the BWD? �(es ❑ No Comr�ents: <br />Does BWD pasitioning meeis minimum sfope requiremen# of >1°!0? [�`Yes ❑ No Comments; <br />Can BWD be pul�ed out for inspectian and maintenance after lflasenir�g thumb screw? j��s ❑�� <br />ls 8WD Iocited into the proper position ar� thumb screw tightened7 [`�'es ❑ No <br />Circle the BWD co .�rrgation cover f t}s�cape araa)/trafficload bearing cover (drive su�face)/ a�cess haCch (building) <br />Was property ow awn the location ofi the inst e BWD? [�les ❑ No Cornments: <br />( <br />�.-� � J Date: � � ? � <br />Property Owner's Signat��re: — <br />fnstalle�s Signatur ' �~ - - �a��; -a- '"�' � '�T �z <br />Revision: 2 1 � Friday, September 12, 2014 <br />