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. � � .� i <br /> BACKWATER PREVENTION DEVICE FINAL <br /> � <br /> . INSTALL4T{ON GFiECKUST <br /> � <br /> � � �Inslallation Company Name and Conlact In(o:__�.,�ri� PT��LL.�S ! ��-l.��1�i}j��; � /�;(_ <br /> Date Backivater Prevention device(BINQ)was installed� � .�7i Date this form�vas complet�d y '/5 ZJ/S <br /> Installation Property O�qner Name and Contact In(o: � Prrr� �e:�¢rsP� <br /> � y. <br /> Property Nddress: �5 ,7 7 �u.�%�. �ue_L' ve.r-c.� �J� �LA! <br /> i <br /> Pre-Install�tion Inspection Checklist: � <br /> All ifems wsf he checked 'Yes'in ader for a BWD to be consrdered/or installation <br /> Is there a 6asemenl or!evel o(the house that is at or near assumed se�ver main elevation?� 'e; ❑ No <br /> ' ❑ <br /> P,re ihere fixfures in the house located helow the upsiream sev;er manhole rim elevation?[�es No <br /> Is the side sev:er currently LINFROTECTED from sewer backups(does r�ot have a BIND inslalled)? �s ❑ No <br /> Sife Inspection Checklist: , <br /> FlII items musf be checked'Yes'be(ore inspeclion is considered co Plete <br /> �r�r�s side sevrer TV inspected from building lo se��ver main? (es �] No �Condition _ <br /> Does side sevaer have at least 1%slope irom ihe building to sewer main? (]�'Yes ❑ No D/escribe: <br /> Have all�uilding sewer drain conneclions to the side sew,er been idenlifibd and located? [v}'Yes ❑ Nn <br /> Have all property storm drainage connections to the side se�ver been identified and lor.aled? []'�es ❑ No <br /> Has property been evalualed (or drainage deficiencies vrith(indings communicaled lo property owner? ❑ Yes ❑ No <br /> � <br /> � Installation Details: i <br /> N�hal type�nd hrand oi BIND�vas inslalled a�this site(Clean Check E3WV, Grinder pump, elc.):�'L,.;.�N n{�n�,� _ <br /> Vdhere v�as ihe devir.e installeA (general description,attach map)7 �a-c-�c �..i n �f' r�c-,c�- �-,i <br /> _ SOw'+'� I,.re_S-�' �,9r� G� ra,ra [r <br /> rJ <br /> Ih�as Ihere any olher sevrer or slorm drainage work compieted in con un�?ion with the BWU�vork? Is so please describe: 1`Y-d <br /> Installalion Checklist: i <br /> Aie all doemspouts and sile drainage disconnecled from upslream o(�t�he/�BIND? Q Yes ❑ No Cnmments:____ <br /> Does DN�D positioniny meets minimum slope requirement of >1%? �iY�°s ❑ No Comments: <br /> Can BIND be pulled out for inspection and maintenanr,s after loosening t�m b screw7 [if Yes ❑ No <br /> Is BIWD locked irto Ihe proper pnsition and thumb screv�tightened? �Yes ❑ No <br /> Circle the BWD cov�iwqati `,��scape ar�lraitic load bear�ng cover(drive sur(a�e)/access hatch(building) <br /> V��as property,ov✓ner slict�, a ed�14�D? E]�s I❑ No Commenls: <br /> IPro`perty Own'er"s Signatur . � �2�' , pa�7 _` <br /> � �ry�.�-_ C=_, v-�� -/,S <br /> Inslaller's Signature: i��IK��� . ��,�y.� i p���, _ <br /> Revision: � i I Monday,Sep[ember 15, 1014 <br />