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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contacl Info:1 <br />pate Backvrater Prevention tlevice (BIND) was <br />�o�-�1�5=�((�l3 <br />Installation Property Owner N2m� and Coni�cf mfo: �� I �IUiu.SG�?�V� (�"� 7'��'� I <br />� <br />PropertyAddress:��p�l�(efZ ��� <br />Pre•Installation inspection Checklist: <br />Af! items musf 6e checked 'Yes' in order /or a BIND to be considered (or instaliation <br />Is there a basement or le��el of the house that is at or near assumed sewer main elevation7 Yes ❑ No <br />Are there iixtures in the house located below lhe upstream sewer manhole rim elevation? Yes ❑ No <br />Is lhe side sev�er currenfly UNf�ROTECTEO from sewer backups (does not have a BIND insfalled)? � Yes ❑ No <br />Site Inspection Checklist: <br />AI! items musl6e checJced 'Yes' before inspection is considered Gomplefe <br />1 <br />Was side sewer TV inspe�ted from building to seover main? � Yes ❑ No Condition: �} <br />Does side sewer have at least 1% slope irom tHe buildirig to sewer maln? ['� Yes ❑ No Describe: �1`� \ <br />Have all building seeier drain connections to the side sewer been identified and localed7 � Y�e,sI ❑ No <br />Have all pfoperfy slorm drainage connections to lhe side sewer been iden(ified and located? L�'Yes ❑ No <br />Has property 6een evaluaied for drainage deficiencies tvilh findings contmunicated to property oivner7 �Yes ❑ No <br />Installation Details: , <br />What type and hrend of B�VD was installed at this site Clean Che BINV, Grinder pump, etc.): ' P� � �� <br />�Vhere was the device installed (general description, altae p)? � L (.�fZn�2R rv� � 4f' n�� r��rV <br />Was tliere any oiher sewer or slorm tlrainage work completed in conjunctinn with Ihe BWD work'7 Is so please describe: �� <br />Installation Checklist: <br />Are all dov��nspouls and sile drainage disconnected irom upstream of th BWD? Yes ❑ �'o Comme�nis: <br />� <br />Does BWD positioning meets mimmum slope requiremem .f >1 %? Yes �] No Cpmments: � _ <br />Can BWD be pulled oul for inspection and maintenance after loosening umb scre�v? ��Yes ❑ No <br />Is BWD locked into the proper position antl ihun re�v tightened? �Yes ❑ No <br />Circle llie BWD cover: irrigation cove (landscape area / tra�c loa bearing cover (drive surface) ! access hatch (building) <br />Was property ovaner sho�vn the location of ihe iristalled BWD? [�Yes ❑ No Comments: <br />Property Ovmer's Signature: `��� Dafe: � �'��I� <br />Install�r'sSignafur�: `�. �4M-P % Date: ���—a0�s <br />Revision: 2 1 . Monday, September 15, 2014 <br />