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�� -r� ��v� -r�o� vi�� Fd ,��. �� <br /> � ����r���. �'�� ������..i��r <br /> �`��4�.�;�9�7 ��-��`g� �" �i�+� `��.�:i.--a'�` �.,.�,,� <br /> e <br /> installation Company Name and Contact Info:�� -� p - �; , �� •� �� ' �� �� � �� � �� <br /> Date Backwater Prevention device (BWD)was installetl:` t� t�. Date this form was completed: `'t �� � <br /> ln5tallati�n Propetty�wner Name and Contact lnfo: �--���a��-� �- �"�'�'1'� �''��`������ �-�-�°����-�������� <br /> _ -� - ., ` <br /> Property Address: �a�1�'� ��=��ti�` �`'��- ,� �.��`��=� �1��� ��� ��,�-C%�, <br /> Pre-Installation Inspection Checklist: <br /> A11 ifems rnust be checked `Yes'in order for a BWD fa be cansidered for instal(ation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation? �Yes ❑ No <br /> Ar�fhere fixtures in the house located below the upsfream sewer manhoie rim elevation?� Yes ❑ No ����x� <br /> � <br /> ls the side sewer currently IJNPROTEC7ED from sewer baci<ups (daes not have a B�,'l�D installed)?�Yes ❑ No � <br /> Sifie Inspec#ion Checklist: <br /> AJl items must be checkerl`Yes'hefore inspection is considered complete <br /> Was side sewer 7U inspected#rom buifding to sewer main? [�Yes ❑ No Condition_ ��� � <br /> � <br /> Does side sewer have at least�%slope from the buiiding to sewer main? [��'es ❑ No Qescribe: � <br /> Have all building sewer drain connections to the side sewer been identified and locafed? [c�-3�'es ❑ No � <br /> Have all property storm drainage connections to fhe side sewer been identifiied and located? �Yes ❑ No : <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? �.Yes ❑ No ' <br /> lnstallation De#ails: �,_.�, ����,,, �-.,_ � <br /> What type antl brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.):���-�Ji--�� � <br /> Where was the device installed (generaf description, attach map)? _� � ��__,��f�+�{.�1 T� � <br /> � <br /> � <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? ]s so please describe:_ <br /> �.�l�a.� .E <br /> [nstallatian Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the 61ND?�,Yes ❑ No Comments: <br /> aoes BWD positioning meets minimum s(ope requiremenf af>1%? � s ❑ Na Comments: <br /> Can BWD �e u11etl out fior ins ection and maintenance afiter loosenin thumb screw? es ❑ Na <br /> P P .,�-Y <br /> Is BWD lociced info the proper�osition and thumb screw tightened? �Yes ❑ No <br /> Circle the BWD cover irrigation cover I�scape area)1 traffic load bearing cover(drive surface)!access hatch (building) <br /> Was property owner sh ocation of the installed BWD? [�'es ❑ No Comments: , <br /> / <br /> Property Owner's Signature: `� r �..�.�.�,,�:T�-� ., Date: � �� � � <br /> r <br /> Installer's Signature:_ Date: � <br /> Revision:2 1 Friday,September 12, 2014 <br />