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:� � � BACKWATER PFtEVENTION DEVICE FINAL <br /> � � fNSTALLATION CHECKLIST <br /> Insfallation Cor�pany Nzme and Coraact Info:�.,�ii� ���Ll�S �L-l'I '1��rS IA�(� (��( <br /> Cate Backwaler Pre;�enlion device (B1ND)was icslalled:� 3 Z,� pzte this (orm v�as completecl � y ,�3 7,ys <br /> ir.;;al!ation Property O��rner Name and Contact�n(o:_ , , �'M.�–J� <br /> ?ropert,.Address 7 �13! . l�r_��"�e l�Qr +1U0 �UEl.rz.hi– �:t�n ��5�..81_� <br /> Pre-Installation Inspectio�i Checklist: <br /> AN iterns m�;�be checked 'Yr.s'in order�nr a BI�JD to be cons;dered(orrnstafla,ion <br /> Is chere a b2sement or level of the nouse (hat s at or near assumed sPwer main elevation? Yes ❑tJo <br /> Are Ihere fxtures in the honse located belo�v Iha uostream sewer manhole rim elevation? i Yes ❑ � <br /> I.; fh=;ide se�ver currently UNPROTECT�D from sev;er backups (does rol have a 81ND instal!ed)� [�Yes L� No <br /> Site Inspection Checklist: <br /> �1r rt�`ms mcst Ge cl,eckea 'Yes'be(ore inspecfion rs censiaered co ple(e <br /> :':as side sea�2r Pl inspected i;om builtlina fo se�ver main7 Yes ❑ No CordiScn <br /> Does side seiaer have at least i 9�o slope from the buildino fo sevder main7 [�Yes ❑ No Describe: <br /> Have all buildino seerer drain r,onne�tions lo the side se�ver been identified ano located% I 1'es ❑ �o <br /> Have all oroperty storm drainage connections to the side se�ver been identified a�d located? [�Yes ❑ No <br /> Has preperty been evalualed for dr2inage deficiencies:vi(h findngs communicatea to property ou�ner? �es ❑ N� <br /> Installation Details: <br /> 1Nhat lype anci brand of BWO �vas installed a�this sile(Clean Check B�AN, Grinder pump, elc.): C' i�� C•%e c� <br /> '.�Vhere �vas the device installed aeneral descn tion, altar,h ma " �y(((-``` �^. <br /> �, P P)' �nt-�{'l. .C�d�_,•:�45 � LI eG' <br /> � ` �_��-� . ���' � <br /> Jn.dySL � `-o �c . 3 �� o K�,�u _a.^� <br /> �^.�as ihere any other sewer or storm drainage vrerk cemphated in conjunr,tion �vith the BVJD work� Is so ple�3se describe �p <br /> Installation Checklist <br /> ,'�re �II do�vnspeufs and sife drainage disconnecled Irom upsiream of lhe BWD? 1'es ❑ No Commenl,� <br /> Lces �tiVD pcsifioniny rneeis minimum slope requiremenl o`>1°c7 ��es ❑ No Co ments <br /> Can 6WD be pulled oul for inspection and mainlenance afler loosening Ihu�ih screw? [�Yes ❑ No <br /> Is BWD locked intu the proper posilion and thumb screw fightened? [�Yes ❑ No <br /> C�rcle Ihe BIND cover: i�wx(landscape area)/tra((ic load bearing cever(drive surface)/access hafch(buildinq) <br /> !Nas property o��mer sho����e�o�tion of the installed BIND? _ Yes ❑ No Comments: <br /> � — <br /> . IFru�"`(y Owner;ssSi�natuie'_ 0�1�-�,r(�$-L�.��yv„�"�J 'Daf�: �?���01 S <br /> ,, �� � � ----�L---------- <br /> Ins;aller's Signalure: � ��,Q� _ Dale: •7.3 2�!� _ <br /> Revision: 7 1 Mnnda S�ptember ]5, . 01�1 I <br /> Y, , <br />