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BACKWATER PREVENTION DEVICE FINAL <br />E„ INSTALLATION CHECKLIST <br />i►Y1 ri call1 E;`fit c. <br />r <br />Installation Company Name and Contact Info;7�.Cr t? 61 7�ii_ -C7,540 i)2-i <br />Date Backwater Prevention device (MID) was installed: Date <br />I _1_ Date this form was completed. <br />Installation Property Owner Name and Contact Info: qtJ�_`/ _ rt_k t � ,5 _ f �__ �2� '} <br />r <br />Property Address: - —Da - v r=_C1( LOQ d (2 1 -- -- <br />Pre-Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a BIND to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? [K Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? ® Yes ❑ No <br />Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? 5 Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from building to sewer main? [Xc Yes ❑ No Condition_: <br />Does side sewer have at least 1 % slope from the building to sewer main? LYes ❑ No Describe; <br />Have all building sewer drain connections to the side sewer been identified and located? [PYes ❑ No <br />Have all property storm drainage connections to the side sewer been identified and located? [R'Yes ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? [ 'Yes ❑ No <br />Installation Details: <br />What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc".): <br />Where was the device installed (general description, attach map)? '-> l P <br />Was there any other sewer or storm drainage work completed in conjunction with the BVJD work? Is so please describe: _ <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BIND? ["Yes [:]No Comments - <br />Does BWD positioning meets minimum slope requirement of >1 %? QaYes L I No Comments _ <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? Wes ❑ No <br />Is BVVD locked into the proper position and thumb screw tightened? [ Yes ❑ No <br />Circle the Blh'D cove 'rri a er pe are trffic load bearin cover a)rive surface I access hatch (building) <br />Was property owner shown the location of the installed BVJD? Tes ❑ No Comments: <br />Property Owner's Signature: <br />Installer's <br />Dated <br />Date; <br />Revision: 2 i—,,/ 1 rriday, September 12, 2014 <br />