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��e,�P�VVpeT'ER PR�����`l�l� D�VIC� FIiV�L <br /> E� IlVS1'ALLAT�ON ���C�CL[S1' <br /> Installation Company Name and Contact Info:�������4 ����J�-/Sf�;7 <br /> Date Backwater Prevention device (BWD) was instailed: Date this farm was completed: <br /> Installation Property Owner Name and Contact fnfo: y�.�C/ TrrrQ�c ��i�i��f' G/� ��Oj <br /> Property Address: <br /> �re-lnstallation lnspection Checklist: <br /> A!!rfems must be checked `Yes'in order for a BWD fo be consrdered for insfallafion <br /> Is fhere a basement or]evel ofi the house that is at or near assumed sewer main elevation? �Yes ❑ No <br /> Are there fixtures in th� house located below the upstream sewer manhole rim efevation?�] Yes ❑ No <br /> Is the side seUrer currentEy UNPROTECTED from sewer backups (daes not have a BWD installed}? �Yes ❑ No <br /> Site lnspection Check(isf: <br /> A1!rtems must be checked`Yes'ber'ore tnspecfior�rs considered complefe <br /> Was side sewer 7V inspected from building to sewer mai�? �Yes ❑ No Condition: ��C <br /> Does side sewer have at least 1°/o sfope from the building to sewer main? �Yes ❑ No Describe: <br /> Have all building sewer drain cannecfions to the side sewer been ident�fied and focafed? X�Yes ❑ No ' <br /> Have all property storm drainage connecfions to the side sevrer been identified and lacated? �Yes ❑ No <br /> Has proper�y been evaluated far arainage defiiciencies with findings communicated fo property owner? �Yes ❑ No <br /> [nstallation Details: <br /> Whaf type and brand of BWD was installed at this sife(Clean Check BWV, Grinder pump, etc.): C/�-,,, ("�(cc� <br /> lNhere was fhe device instailed (generaf description,atfach map}? 5� cc�-lx-� a� �dL•sc.. <br /> Was there any other sewer ar storm drainage work campleted in conjunctian with the BWG work? Is s�please describp: _ <br /> {nstallation Checklist: <br /> Are al! dov�nspoufs and site drainage discannected from upstream cf the BWD? �.Yes ❑ No Comments: <br /> Daes BWD positioning meets minimum slope requirement of>1°/a? �Yes ❑ No Commenfs; ' <br /> Can BWd be pulfed out for inspection and maintenance after loosening thumb screw? C Yes ❑ No ' <br /> ls BWD locked into the proper positian and thumb saew tightened? .�Yes ❑ No ' <br /> I <br /> Circfe fhe BWD cover: irrigation cover(landscape area) 1 traffic load bearing cover(drive surface}/access hatch (building) ' <br /> Was praperty owner shown the locatian of the installed BWD? Yes ❑ No Camments: , <br /> _ ,'-y� � ; ,- ! <br /> Property Owner's Signature:�`�-� ,�C � ' — ---� Date: � � ` � � ' 1 � <br /> _,,,. <br /> lnsfafler's Signature: d/� Dafe; ,�/� -;✓� <br /> Revision: 2 1 Monday,Septernber 15, 2014 <br /> i i <br /> � <br />