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BACKWATER PREVENTION DEVICE FINAL <br />4-wrr <br />INSTALLATION CHECKLIST <br />*+ `J(.de `7c,zr:"(r L_%-C <br />Installation Company Name and Contact lnlo:.ire CC Qi GIB 4.?- : X✓ -6 S(I �' l r t 14 U K x?n <br />Dale Backwater Prevention device (BIND) was installed:A�kaIj5 Date this form was completed: <br />Installation Property Owner Name and >rContact Info: ffl-l F i h ✓i Property Address: __34aa_ Ct)Cj kPn� <br />Pre installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BIND to be considered for installation <br />Is the,, abasement or level of the house that is at or near assumed sewer main elevation? [g Yes []No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? [F Yes []No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? )2 Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete Was side sewer TV inspected from building -to sewer main? P Yes ❑ No Condition: 13n <br />Md. <br />Does side sewer have at least 1% slope from the building to sewer main? FYes ❑ No Describe: <br />Have all building server drain connections to the side sewer been identified and located? � es ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? FRNes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [Wes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): s�r <br />Where was the device installed (general description, attach map)?.(' <br />Was there any other sewer or storm drainage work co tpteted in conjunction with the BWD work? Is so please describe. _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? 0 Yes ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement of >190? F Yes ❑ No Comments: <br />Can BWD he pulled out for inspection and maintenance after loosening thumb screw? f'Yes El No <br />Is BWD locked into the proper position and thumb screw fightened? P Yes ❑ No /j' <br />Circle the BWD cover: rigalion co . , landscape area) I traffic load bearing cover (drive surface) / access hatch (building) <br />Was property owner shown the location of the installed BWD? P Yes ❑ No Comments: <br />Property Owner's Signature: <br />Installers Signaturq <br />Date: /IJr'J A4—, 201!Z_ <br />Dale: `2Z —--- <br />Revision: 2 1 (J 1 Friday, September 12, 2014 <br />