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� BACKWATER PREVENTION DEVICE FINAL <br /> INSTAI.LATION CHECKLIST <br /> Installation Company Name and Contact InFo: ��'�� ��rn�I �(r L.�..0 <br /> Date Backwater P�evention device (B'N�)w�s installed:��30- /S Date ihis form was completed: -, U- �S <br /> I�stallation Property Oemer Name and Contacl Info: t-�4�'-R-� r501-!r�SorJ <br /> Property Address: 1421 l�on�F�,�4�e-(� R v�� CVLt�-�='Tt' c.��- 9-� 21� � <br /> Fre•Installation Inspeotion �hec{clist: <br /> All ilems must be checked `Yes'in order!ar a BV✓D fo be considered for instailation <br /> Is lhere a basement or level ot the hous=that is at or near assumed sewer main elevation? f�Yes ❑No <br /> Are there fxtures in the house located belcw the upstream sel:�er manhole nm elevation?�Yes ❑ �do <br /> Is the side setver cur,ently UNPROTECTED from se�t�er backups (does not have a BWD installed)7 (7�,Yes ❑ tJo <br /> Site Inspection Checklist: <br /> Ali items must be checked'Yes'beto�e inspection is conside�ed complete <br /> L�'as e' '�sewer TV inspected irom 6uilding to sewer mainl [�,Yes ❑ No CondiOon: OLG� C�v�c2c.T�� p �cj <br /> Does side sewer have at least 1% slope from the building fo sewer main? [�Yes ❑ No Describe: <br /> Have all building sewer drain conneclions to the s�de sewer been identified and located? �,Yes ❑ No <br /> Have all property storm drainage connections tu the side sewer been idenli6ed and localed? �Yes ❑ No <br /> Has property been evalualed(or drainaoe deficiencies a�itn findings communicated to property ovme� �Yes ❑ No <br /> Instaliatfon Details: <br /> V�mat type and �rand oi BIND was installed at this site(Clean Cheak BINV, Grinder pump, etc.): �'�'�h' �-��cl< <br /> Where tivas the device instailed(general description, attaoh map)� <br /> 14�as there any other sewer or storm drainage work completed in conjunclion with the BWD work? Is so please describe:_ <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream o(lhe BWD? (�Yes ❑ No Comments: <br /> Dcas BWD posifioning meets minimum slope requirement of>1%? (�,Yes ❑ No Comments: <br /> Can BtND be pulled out for inspection and mainlenanee after loosening lhumb screv�? I�Yes ❑No <br /> Is BIND locketl into ihe proper position and thumb screw tightened? �Yes ❑ No <br /> Circie the B1h'D cover.irrig?lion cover(landscape area)I traf6c load bearing cover(drive surface)1 access hatch (buiiding) <br /> Was property owner shown ihe locatior of the ir�stalled BWD? [�J Yes ❑No Comments: <br /> Gd�.r.ew.;u — �_, <br /> Property 0wner's Signalure: �> �,'��./.�,.i/��� Date: � —�� - � � <br /> Installer's Signatur� � �i�/v �---'J y Dale:4" 3� "- �-� <br /> Revision: 2 1 Tuesday,September 16,2014 <br />