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�ACK1iV6�T�b� �REVE�l�BO� C��!/9CE �ER�A�. <br />I�STA��ATI�� �F��CKLI�� <br />,�►��r� c«n �.�� � � � � �de : c.��, L 1-G <br />; ., - - <br />Installation Company Name and Contact Info: ,• .� <br />Date Backe�ater Prevention device (BIND) �vas ins <br />Inslallation Proped <br />Property Address: <br />Date this torm was <br />Pre-Installation Inspection Checklist: <br />Ail ifems must be checked 'Yes' in order for a 6V✓D to be considered (or install�rion <br />Is there a basement or level of the house that is al or near assumed sewer main elevation? �Yes ❑ No <br />Are ihere fixtures in the house Iocaled betotiv Ihe upsiream se�ver manhole rim ele��afion7�j Yes ❑ No <br />Is the side setiver currently UNPROTECTED irom se���er backups (does not have a BWD installed)?��Yes ❑ No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' be(ore inspeciion is considered ccmplete <br />Was side sewer TV inspected irom building io se�:�er main7 � Yes ❑ No Condition: _�� � Cl <br />�oes side sewer have at lezst 1% slope trom Ihe building to sewer main? �Yes ❑ No Describe: <br />Have ail building setver drain connec6ons to the side sewer been identified and located? �Yes ❑ No <br />Have all property starm drainage conrections to the side se�ver been identified and lo�aled? [�Yes � No <br />Nas property been evaluated tor drainage deficiencies �viih findings communicated to properry owner? �°Yes ❑ No <br />Installation Details: /� ^ <br />lNhat type and bra�d of BIND v.�as installed at lhis site (Clean Check Bl4N, Grintler puma, elc.): �'iP (�'f(Y' ��l'�. �� <br />INhere �vas Ihe device inslalled (general descripiion, attach map)? �-1-' E' C ����1.[.:"_. �tI' c�S�L 'c �' <br />Was Ihere any other see+er or storm drainage H�ork comploted in conjuoction with the BWD v+otk7 Is so please describe: _ <br />Installation Checklist: <br />Ar, all do�t�nspouts �nd site drainage disconnected frnm upslream of the �VJD? �Xes ❑ No Commenis: <br />Does E3VVD posilioning meets minimum siope requirement of >t°/a? � Yes ❑ No Comments: _ <br />Can BWD be pulled out for inspeclion and maintenance afler loosening thumb screiv? �c] Yes ❑ No <br />Is 8WD lacked into tl�e proper position and Ihumb scre�ti� lighlened? „ Yes ❑ No <br />Circle lhe BWD cover irr ,igailon cover (laAilscape area) I tra(fi� load bearing r,over (drive surtaee)1 access h2ich (bulltling) <br />lNas property owner sho�+m Ihe localion of the installed 61ND? � Yes ❑ No Comments: <br />,�' � Il (� <br />Property O�mer s Sionalure: .� � Date: <br />Inslaller's Signalure: � � '� L•i_,(! Dale: ; � �/r '� <br />� , , <br />Revision: 2 1 Friday.5ep[ember ]2, 201A <br />