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BACKWAT�R PREVENTION DEVICE FINAL <br /> a, INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: - ,�� {'.'N;U� L LC' <br /> . � � - <br /> Dz1e Backwa�er Prevention dewce (BIND)�eas inslalled: 3-5- 2�i 5 _.Date Ihis form was con�pieted:3-6 -zo�5 <br /> Installalion Property Owner Neme and Conlact info.�G n ` �I��N��n�� 4 ZS'3S3 -� 8LL- <br /> PreperlyAddress: vZ�OoZ CJY�incQ �� C�re�����ZU� <br /> Pre•Installation Inspection Checklist: <br /> All dems must be checked`Yes'in order for a BWD to be conside�ed(or installation <br /> Is there a basement or ievel of the house thai is al ar near assumed sewer main ele��ation?�c Yes ❑ No <br /> Ara Ihere fxlures in the house locatetl belo��+the upstream sevrer manho!e rim elevation?,�Yes ❑ No <br /> Is fh=side sewer currently UNPROTECTED from sevaer backups(does nol have a BWD inslalled)? � Yes ❑ No <br /> Site Inspection Checklist: <br /> All i;ems must be checked'Yes'before inspecfion rs consid=red complete <br /> INas side sev�2r N inspected (rom building to sewer main? �Yes ❑ No Condition: <br /> Does side sewer hava at least 1% slope from the building to sewer main7 [�Yes ❑ No Describe: <br /> Have all building sewer drain connections to Ihe side sewer been ideniifed and Iocated? (�.Yes ❑ No <br /> Have all property storm drainage conneclions to Ihe side se�ver been identified and localed? I J�,Yes ❑ No <br /> Has property been eva�uated ior drainage deficiencies�vilh findings communicated le property o�n�ner? �Yes ❑ No <br /> Installation Details: <br /> Whal type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, elc.): C�e��� �-�'`�c-1�- <br /> bVhere vras the device inslalled(general description, atlach map)? Q'�}S�� �v v S� — <br /> \Nas there any other sewer or sform drainage work compleled in conjunction �vilh the 8WD work? Is so please descnbe� __ <br /> v�U <br /> Installation Checklis! <br /> �re all do�vnspouts and site drainage disconnecled from upstream ot the BWD7 [3�Yes ❑No Commenls: <br /> Does BWD positioni�g meels minimum slope requiremem of >1°0? �Yes ❑ IJo Comments: <br /> Can BWD be pulled out for inspection and maintenance afier loosening ihumb screw? �Yes ❑ tJo <br /> Is BVJD locked inlo the proper position a cL�humb scre�v tightened? �Yes ❑ No <br /> Circle the CiWD cover: irrigation cov r Qandscape a a 1 iraffic load bearing cover(drive suriace)!access hatch (building) <br /> N�as property ovmer shown the localion of the instalied BWD? �es ❑ No Comments. <br /> Property Owner's Signature: � i�f' //h�u ,EJ��`"-' Dale: �'� �Z��s <br /> Installer's Signature: ti "��-R ��� Dale: �' �7��5 <br /> :!zvision: 2 t Friday, September 12, Z014 <br />