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BACKWATER PREVENTION DEVICE FINAL <br />4M77 INSTALLATION CHECKLIST <br />Mri can <br />Installation Company Name and Contact Info:Sx.C.0 ' = 4 <br />Dale Backwater Prevention device (BIND) was installed:_ Date this form was completed: <br />Installation Property owner Name and Contact Info: Vi1,\ — <:;:k 1 to Ad 5 ` <br />Property Address: Q 2 _o2 T I? 'a?n( <br />Pre -installation Inspection Checklist: <br />All items must be checked 'Yes' in order fora BWD to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? 0 Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? 2f Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? [Z Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete n^- <br />Was side sewer TV inspected from building to sewer main? P Yes ❑ No Condition: d <br />Does side sewer have at least 1% slope from the building to sewer main? Yes ❑ No Describe: <br />Have all building sewer drain connections to the side sewer been identified and located? RrYes [-]No <br />Have all property storm drainage connections to the side sewer been identified and located? [Yes []No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? f f Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): g['c,�1Ci 'Cr, <br />Where was the device installed (general description, attach map)? `12C e L21� �C �>3 S. od - Aca l+ <br />Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: _ <br />rl Q <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? ffYes ❑ No Comments: <br />Does BWD positioning meels minimum slope requirement of >t%? [�J Yes ❑ No Comments: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? (XrYes ❑ No <br />Is BWD locked into the proper position and thumb screw tightened? (J Yes ❑ No <br />Circle the BWD cov . irrigation cover landscape area) I traffic load bearing cover (drive surface) I access hatch (building) <br />Was property owner shown the location of the installed BWD? RTYes ❑ No Comments: <br />L-j r <br />Property Owners Signature: ✓ / � (y Date: _ 6 , <br />Installer's Signature: Date: t _ <br />Revision:2 1 rriday, September 12, 2014 <br />