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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installalion Company Name and Ccntact Inio: �j <br />Date Back�ti�ater Prevention device (BIND� �vas insta <br />Inslallation Property Owner Name and Contact Info: <br />ProperlyAddress: �'j„�i� �,nl`1r4��i <br />—/5 Date this form was <br />Pre•Installation Inspection Checklist: <br />All ilerns must be checked'Yes' in order (or a BWD fo be considered forinsfallation <br />Is ihere a basement or level of lhe house thal is al or near assumed sewer main elevation7�'es ❑ No <br />Are ihere fixtures in the house located below the upslream sev�er manhole rim elevation?�Yes ❑ No <br />Is the side sevier currently UNPROTECTED from sewer backups (does not have a BLND installed)?�Yes ❑ No <br />Site Inspection Checklist• <br />All ilems must 6e checked'Yes' before inspection is considered corpplete <br />Was side sewer TV inspected from building to sewer main? �J eY s❑ No /Condilion: �oo � <br />Does side sewer liave at leasl 1%slope irom the building to sewer main? Q'Yes ❑ No Describe: <br />Have all building sewer drain connections to lhe side sewer been idenlified and latated7 �es ❑ No <br />Have all property storm drainage connections lo the side sevier been identified and located? [� Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property ownerl �es ❑ No <br />Installation Details: /� <br />What lype and brand ot BWD �vas inslailed at Ihis sito (Clean Check BWV, Grindenr pump, etc.): C.. <br />Where tvas lhe device inslalled (general description, attach map)? ��� l�9ILD,�J(_ � yi.LG . <br />1 <br />Was there any other sewer or storm drainage work cumpleted in conjunction with the BWD �vork? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainago disconnecled 6om upslream o( lhe OWD? � Yes ❑ No Commenls: <br />Does BWD posilioning meets minimum slope requirement of >t%? � Yes � No Commenis: <br />Can BWD be pulied out for inspeclion and mainlenance after loosening Ihumb screw? � Yes ❑ No <br />Is BWD locked into the proper posilion and thumb screw tightened? �Yes ❑ No <br />Circle the BWD cover: irrigation cover (landscape area) / Uaffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shovm fhe location of the inslalled BWD? f�Yes ❑ Na Comments: <br />l <br />Property Ovaner's Signature: �����( � ` � - Date: `1 � � �s <br />Installer's Signature: Dale: � � — /� <br />Re�ision: 2 1 Friday, Sep[ember 12, 2014 <br />