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i <br /> � <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL I <br /> d INSTALLATIOIV CHECKLIST ; <br /> i <br /> �nc�ri c�:�n ���"�c� ^Y {��de 5C-���1', L LG � <br /> Installatio�Company Name and Contact Into:�r��•.��' «' ( ' `i�.�� � '��`'�I�� '��` ��'�.� ����"�� � <br /> . � <br /> Dale Backwater Prevenlion device(BIND)was insialled:.�.laXl� Date ihis iorm��as completed'`�- ; <br /> Installation Property O�ti'ner Name and Contact Info: 1' Y��� �n f> rN v � '"��� � '�L-�v�i� "�� ! <br /> � � <br /> PropertyAddress: l���P L,�� �' e)P/t0-k�� Q���n� ! <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked 'Yes'in orde�ior a BWD to 6e considered for insiallation � <br /> • Is there a basement or level of ihe house that is at or near assumed sewer main elevation? �Yes ❑ No <br /> Are there fixtures in the house located below the upsiream sewer manho'e rim elevation? �-Yes ❑ No <br /> Is fhe side sewer currenfly UNPROTECTED from sev:er backups(does not have a BWD inslalled)?[�Yes ❑ No ` <br /> I <br /> Site Inspection Checklist: I <br /> A!1 items must 6e checked 'Yes'before inspection is considered complete /� ; <br /> Was side sewer TV inspected from buildingdo se�ver main? [�lYes ❑ No Condition' (�[Fj� j <br /> Does side sewer have at least 1°/a slope from the building to sewer mainl �fes ❑ No Describe: � <br /> Have all building sewer drain connections to the side sev.�er been identified and locafed? [�'es ❑No ! <br /> � <br /> Have all property storm drainage connections to Ihe side sewer been identified and located? [�'es ❑ No 1 <br /> Has property been evaluated for drainage deficiencies with 6ndings communicated to property ovmer? ,Q Yes ❑ No <br /> Installation Details: <br /> What type and brand oi BWD v�as installed at this site(Clean Check BWV, Grinder pump,eic.): � ' - � <br /> ' - ' I i <br /> l4�here was the deviee installed (general descriplion,aflach map)7��E' ����0<'� e.�t� S IF f Il'- � <br /> i <br /> VJas there any other se�ver or slorm drainage�vork com'p`leIted in conju�clion with Ihe BWD�rork?Is so please describe:_ � <br /> _.!�—v'l� ' <br /> � <br /> Installation Checklist: <br /> Are all dcwnspouts and site drainage disconnected(rum upstream of the DWD? l�'S'es ❑ No Comments: <br /> Does 8WD posilioning meets minimum slope requirement of>1°6? �Yes ❑ No Cammenls: i <br /> Can B:ND be pulietl out for inspeciion and mainlenance afler Ioosenina thumb screw? �>Yes ❑ No � <br /> Is DWD locked into the proper position and thumb screw tightened? �es ❑ No ; <br /> Circle the B1ND cover. ngatio cover ntlscape area)/traffic load bearing cover(drive surface)1 access hatr.h(building) <br /> Was property owner sh�ocabon o th instailed BWD? �Yes No CommeMs: <br /> , � � <br /> _ � � ; <br /> Properly Owner's Signature:� Oate: LI' Z� ` 'J � <br /> Installers Signatur . - � Date: Y —I�"�J � <br /> . i <br /> Revision:7 1 Friday,September 12,2014 � <br /> . � <br /> I <br />