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� • ► - '' i � . <br />� � 1 i <br />���� �• • <:� � : <br />�V'� <br />Installation Company Name and Contact Infa: ����p � r�i � � � � � �t ��`` �' �`� � <br />Date 8ackwater Prevention device (BWD) was installed: ��-j- ;��--1 �; Date this form was completed: l,� -�?- � ti <br />n <br />Insfiallation Properfy �wner Name and Contact Info; <br />Property Address: � `�'� � ��t � 1�.�--�- �-��' � <br />Pre-Instailation lnspection Checklist: <br />A!1 ifems must be checked `Yes' in order for a BWD io be consider�d for insfallation <br />fs there a basement or level of the house that is at or near assumed sewer main elevation? [�] Yes ❑ NQ <br />Are there fi�ures in the house located befow the ups#ream sewer manhole rim eEevation? (�] Yes ❑ No <br />Is the side sewer currentfy UNPROiECTED from sewer backups (does not have a BWD installed)? � Yes ❑ No <br />Site Inspection Checklist; <br />A!I ifems musf be checked `Yes' before inspecf�ott is consrclered cample�e <br />Was sfde sewer TV inspected from building to sewer main? �] Yes ❑ No Condit`ion: <br />Does side sewer have at least 1% sfope from the building to sewer main? .t� Yes ❑ No Describe: <br />Nave all building sewer drain connections to the side sewer be�n identified and located? (�] Yes ❑ No <br />Havs afl property storm drainage connecfions to the side sewer been identif�etl and locafied? � Yes ❑ No <br />Has propertJr been ev�luated for drainage defciencies wifh #indings communicafed to property �wner? [] Yes ❑ No <br />lnstaliation Qe�ails. , =-=�---��,�""`� <br />What type and brand of BIND was installed at this s'�t� C(ean Check l�/-,-Gr[�tler pump, etc.�: <br />Where was #he device instalfed (genera3 descriptiQn, atta�n map)? � c� r f�,�i`�f�� � c.� -��E � <br />, �, <br />ln,;,n, n �;,'r� r,�� �i'r�� <br />UVas there any other sewer or sto�m drainage work c�mpleted in conjunction with the BWD work? ls so please describe: ^ <br />�� <br />Insta!{atian Checklist; <br />A,re all downspouts and site drainage disconnected from upstrearn of the SWD? [/� Yes ❑ No �ommenfs: <br />Does BWD positioning meets minimum slope requirement of �1 °lo? � Yes ❑ No Camrnents: <br />Can BWD be pulfetl outfor inspecfion and maintenance after loosening thumb screw? [� Yes ❑ No <br />Is BWD locked into the prs��er: posi�ian-arrd-�i�bs�Lew tightened? ��] Yes ❑ No � <br />Circle the BWD cov t: irrigation cover (landscape are _�-t�aific foad bearrng cover (drive surface)1 access hatch (building) <br />�--_ _. .__�.---------�_-�.e�) f <br />Was property owner shown the location of the installed BWp? � Yes ❑ Na Camments: <br />Property Owner's Signafure: Date: <br />Installe�'s Signafure: � � ��� � Date: �=' - � �5 - � 5��� <br />�-= l <br />Revision: 2 f 1 Friday, September 12, 2414 <br />1 � �'v- <br />