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BACKWATER PREVENTION DEVICE FINAL <br />ilVSTALLAT�ION CHECKLIST <br />Installation Campany �dame and Contac: In(o <br />Date Dackv;ater Prevention device (B1NDj was <br />Insla!lalion Property Ormer Narne and Contact Info <br />Property Address z- <br />Da'te fhis form v�as <br />Pre•Installation Inspection Checklist: <br />Al; iterns must be c7iecked '1'es' in ader la a QV✓D to be cons�ifered lor insfa0ation <br />Is fhere a basement or Ievei cf the hoise tnal is at or near assume�i se�ver main elevafion? �� Yes ❑ No <br />Arc Ihere bxlures in the house located belav Ihe upslream se++er mannole rim eleva6cn7 � Yes ❑ No <br />��, ,��e side sev,er currentiv UIJPROTECTED (rom secrer backups (does not have a B!%�'D installed)7�] Yes ❑ Ko <br />Site Inspeclion Checklist: <br />!'!,;cros miat be checked Yes' be(ore inspeclion is considerea ccmplete <br />:`1as side se�•�er i V inso2cted from budding b sewer main? �Yes ❑ No Condition: <br />Dc�s side sewer h:jve at least 1°o slope from ,h� building to sewer main? [� Yes ❑ No Describe: <br />Have all bwldina se���er drain eonnections lo the side seNer been �denlified and Iccated9 �Yes ❑ No <br />Ha:�e all prope7y storm drainage conrections to lhe ; �oe se:ver been idenUfied and localed� � Yes ❑ vo <br />Has p�cpe^.y been evaluated for drainage deficiencies wilh Ondinos communicatetl to properiy o�•, ner? �%] Yes ❑ No <br />Installation Details: <br />4;�hz1 lype and orand ol B1��D was inslalled al ihis sile (Clean Check <br />� <br />l'Jhere �,�as Ihe device installed (general descripl�on, atlach map)? _ <br />Grinder pump, etc.) �� ./�I.�C� <br />, <br />l':�as there any o!her se.ver or;to�m dra �age e:ork com�le;ed in conjunetion �.vith lhe BV�'D �vor�c7 Is so please describe _ <br />Installation Checklist: <br />Are r+ll dorrr�spouls and sile drainage disconnecled from upstream nf tne BIND� [J Yes ❑ No Canrnents <br />I;o�s f314�D poslLorung meels mimmum slope reawrement o( >i%7�Y2s ❑ No Commenis: <br />Can Bl`dD be pulled out for inspeclion and mainlenance a(ter loosening Ihumb scro�v7 �/]�Yes ❑ No <br />Is Hb?�D locked into tne proper position and Ihumb screw t�ghtened7 � Yes ❑ No <br />C�rcle the BVJD cover: �rrigation cover (lantlscape area)/ tralfc load bearing cover (dnve surface) / access hatch (building) <br />l:'as property o:mer shoem Ihe lacation of the installed BUJD� �Yes ❑ No Comments _ <br />; , I--- <br />i <br />Pioperty Oemer's S��+ ura� �� ' •� ,<. _ ' � Date: ' ��2� ��`-' <br />( G/ �. <br />I istaller's S gnature�— � � Dale �� Z{� �� <br />L <br />Her ,ion� 2 - _ 7 Fridal', S^P[et�bcr 1?, 101d <br />