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� t , �: <br />,.�� <br />� <br />' � �i � �� �' � � i <br />;�_ <br />Instailation Company Name and Cantact I <br />�� � �� � � � <br />� � ,� . „ .� � <br />� Y'��:=;`�a ����� �'���� � �- '� �.�� �-�.�-c--�°�`$ �.�.:: <br />Date BacKwater Pr�vention device (BWD} was instalfed <br />� Date fhis form was completed: �;� ��_ <br />.--�' i _ ; i , t .�_ t <a� �Z� <br />Instailation Property Owner Name and C�ntact Info; �.J �� �`"" 3 �..� 1. �����,5 a�. <br />Properfy Address: ���"_��. �� � �^€`� f �i'r"'r1 �r����� �',�t,.�==�"� �� � �"`--� <br />Pre-Instal[ation Inspection Checklist: <br />AH ifems must be checked `Yes' in order far a&WD to be considered for installation <br />Is there a basement or level of the house that is at or near assum�d sewer mai� e{evation? � Yes ❑ Na <br />Are there fixtures in the house located befow the upstream sewer manhole rim elevation? �Yes ❑ No <br />Is fhe side sewer currently UNPR�TECTED from sewer backups (does not have a BWD instaCietl)? [�-�Yes ❑ No <br />Sifie Inspection Checklist: <br />All ifems mus� be �hecked `Yes' before inspecfron is cons+dered camplete � <br />Was stde sewer TV inspected from buifding to sewer main'� [�1'es ❑ No Condition: �--� �"�:� <br />Qoes side sewer have at least 1% slope from the building to sewer main? [� Yes ❑ No Describe: <br />Have aIl building sewer drain connections to th� sitle sewer bean identified and (acated`? [� Yes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? [�Yes ❑ No <br />Has proper'ty been evaluated for drainage tleficiencies with fintlings communicated to property owner? �Yes ❑ No <br />Installation Details: . , <br />What type and brand of BWD was insta{led at this site (Glean Check BWV, Grinder pump, etc.): %� c:� <br />Where was fhe device installed (genera! description, attach map)? �_ '� ' ', �+ <br />Was there any other sewer ar storrn drair�age work completed in canjunction with #he BWD work? Is so please describe: _ <br />i`,r �,�.� <br />fnstailatiQn Checkiist: <br />Are all downspauts and site drainage disconnected from upstream of the BV11D? �Yes ❑ No Comments: <br />Does S�IVD positioning meets minimum slope requirement of >�%? �i`es ❑ No Camments: <br />Can BII�D he pulled out far inspection ar�d maintenance after ioos�ning thumb screw? �`es ❑�lo <br />Is BWD lock�d into the proper-pns�fic7n�and thumb screw tightened? � Yes ❑ No <br />�-.. <br />Circie the BWD c er: irrigafior�.cover ` dscape area) I traffic load bearing cover (drive sur�ace) / access hatch (building) <br />Was property owner s own the [acation of the installed BWD� Yes ❑ No Comments: <br />� <br />Property Owner's Signature: Date: �' �' ��� <br />installer s Signature� � Date: �� l� <br />Revision: 2 1 � Friday, September 12, 2U14 <br />