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�� <br />I�M� <br />�. <br />�;, , <br />1 � • �- �, ,�. ` � � <br />�. ' � �, <br />j �� � ��:�� <br />lnstallation Company Name antl Gontact info:� � ��= ' � - . `� . <br />Date Backwater Pr <br />.. �- �-- ,�,h�n� ,�,�� ;p�+a1iP�►� ij i� i C� � Date this form was completed:-�. -�� <br />fnstafiation Froper� <br />Property Address: <br />Pre-lnstallatian Inspection Checklist: <br />Aff rtems must be etaecked `Yes' in order for a BWD �o �� ��ssu�med sewer tma�nlelevation? Yes ❑ No <br />Is there a basement or lavel ofi the house that �s at or near � <br />Are there fixtures in the house located below the upstream sewer manhafe rim elevation? C�'�� ?� Yes ❑ No <br />{s the side sewer currently UNPR������� �rom sewer backups (does not have a BWD m }� <br />Site lnspection Checklist. <br />Af1 rtems must be �hecked °Yes' before �ns,peciion is considere� cc�mp�ete �-.�� � <br />Was side sewer TV inspecfed from building to sew�r main? ��`eS ❑�0 c°p��t10�' � <br />Does side sewer have at least �% slope from the buifding to sew�r main? �'eS D�o Describe: <br />Have ai! building sewer drain connections to fhe side sewer been identified and locatad'? [�'Yes ❑��� <br />Have all property storm drainage connections to the side sewer been i�entified and located, [� <br />s ro ert been evaluated for drainage deficiencies with findings communicated ta property owner? �Yes ❑ No <br />Ha p p Y <br />Ins�alfati4n Details. � r � <br />Grinder pump, etc.): <br />What type and brantl of BWD was installed at this site (Ciean Check BWV, `I ^ � <br />, �u� <br />Where was the device installed (genera{ description, aitacfi n�ap}? � <br />Qther sewer or storm drainage work completed 'n conjunetion with the BiND work? !s so please describe; _„_. <br />Was there any .�� r�-� �, <br />lns�allation C�ecklist: � <br />Are all tlownspauts and site drainage disconnected from upstream of the BV�1D? ��� ❑�� �omments: <br />p�es BWD pasitioning meefs minimum slc�pe requir�menfi af >1°l0? �Ye� ❑ <br />No Comments: <br />Can BWD be pulled out for inspection and maint�nance afiter loosening thumb screw? �'Yes Q No <br />�� BWD laeked into the praper position and thumb screw tightened? � Y�� ❑�a <br />Gir�le the BWD eov r: irrigat on ca�e� andscape area) / traffc load bearing cover (driue surface)1 access hatch (bu�lding� <br />�wn the oi c� �f �he instaCied BWD? ' Yes ❑ No Gomments: <br />UVas property owner show � <br />,. � pate: ' � /` ` ' � <br />Pro ert Owner's Signature: � . <br />P Y � Date: ,�� � � � <br />Installer's Signatur �°� � ` �=�'""���� <br />� FrEday, September 12, 201:4 <br />Revision: 2 <br />