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I <br /> � <br /> ��������� ����E������ ��Q���� ����� <br /> � , 9E���"�.��..��B�i� �&�������T <br /> /( ,eri �+C',�;J, ; <br /> Insfallation Company Name and Conlact Info:n;11P'�I C i' a 1 ��ili=�c,` � � � ~ �'� l ,% ' -?="' ''� ! <br /> i—��r r ,7.� �.t'P.. LLL. �� - ,� �,�. � <br /> _ � <br /> Date Backwater Prevention device(BIND)�vas inslalletl:���_ Date ihis form v.�as compleietl:��— ', <br /> �rslallalion Properly O�r+ner Name and Contad In(o:�(�j,���j(�� ��=�i(c�-_-�{��L1_ ! <br /> Property Nddress:���,�„�m�Q('�� /�_I�(�y' � ���nl � <br /> Pre•Installation Inspection Checklist: �i <br /> l�II items musf be checked'Yes'in order�or a 8t4�D to be considered for installation <br /> Is there a basement or ievel oi ihe house fhat is at or near assumed sev�er main elevation?�Yes ❑ No � <br /> tire there fixt�res in the house located below the upstream sewer manhole rim eievation?[�Yes ❑ No ' <br /> �s���s�ue se:�:er currently UNPROTECT�D from se��rer Bac'�cups (does not have a BNJ� instalied)? (,�"Yes ❑ No � <br /> Site Inspectio� Chec{dist: � <br /> All items must 6e chEcked'Yes'before inspection is considered complete /� ' <br /> V:'as side sewer TV inspectetl from building to sewer main? �Yes ❑ No Condition: I�LYi� ! <br /> Does side see�er have at least 1% slope from the building lo see�er main? [�J Yes ❑ No �escribe: i <br /> Have all building se�ver tlrzin connPctions to the side sewer been identi ied and located? (�Yes ❑ No ' <br /> Have all property storm drainage connections to the slde sev�er been identified and loeated? �Yes ❑ No i <br /> Has properiy been evaluated for drainage deficiencies c�ifh findings communicated to property owner? � Yes ❑ No � <br /> Installation Details: <br /> VJhat type and brand of 8WD�vas instalied at this site(Clean Check BIhN, Grinder pump,ztc.): ' r- �-� � <br /> Vdhere was ihe dc�vice installed (general description, atlach mao)? `-�'�ir{�u?���(�- � <br /> I <br /> 1�'as ih,e�rer any other sevler or storm�drainage vrork completed in��cnonjunc�ion with lhe BIND vrork? Is so please describe:_ <br /> ��S.Li�SC:L:.`t�t—j�VLL�_.--�[-��CPiy//1�eiT __ i <br /> Instailation�hecklist: � <br /> Are all downspouts and sile drainage disconnecled 4om upstream of the BNlD? �Yes ❑No Comments <br /> Does BWD positioning meets minimum slope reqwrement of>1%? �Yes ❑Nu Commems:_ _ <br /> Can BWD be pulled o�t for inspection and maintenance atter loosening Ihumb screv,? [�t Yes ❑ No I <br /> Is E3lND locked into lhe proper posifion and thumb screw lighlened? � Yes �J No , <br /> Circle the BIND coveLirigalion cover(I dscape area)/Ira(fic load bearing cover(drive surface)/access hatch (building) <br /> U��as properfy ovmer shown the location of Ihe installed BWD? �"Yes ❑ No Comments: <br /> � <br /> I <br /> Properly Owner's Signature. ,� �� , Date: � � -/. � � <br /> Instalier's Signature: _ Date: 3 • �_ ; <br /> � <br /> Revision: 2 1 Friday, Septem6er 12, 2014 ' <br /> i <br />