1111 41ST ST 2022-05-19 - Laserfiche WebLink

� I BACKW�TER PREVENTION CJEVICE FINAL � INSTALLATION CHECKUST i I Inslallation Company Nzme and Contact Info: M U� I (�-n-� � �{� S 7GU ff1 L U � i Date Back�vaier Prevenfion dEvice(BIND)was installed: �- 17- I r Date lhis form vras completed: '� I (�- 1S ; Inslallation Properiy Ovrner Name and Conta�t I��fo: �'1 u�.�ten S�-e,rc�s `!'�� S ,L 2 �77-�'i Prop�rtyAddress: � � � � L� � � �' ��e,�c�f �-/� G��' 1 i Pre-Installation InspecUon Checkiist: � All items must de chec;ced`Yes'in order for a 814�D�0 6e considered for installation Is there a hasement or level of the hous2 lhat is at or near assumed sewer main elevafion9�Yes ❑ No � Are there fixtures in the hcuse locafed belo�.v the upsiream se�ver manho:e rim elevaGon?�`j Yes ❑ yc Is fhe side se�,t�er currertly U�!PROTECTED from sewer 6ackups (dces �ot have a BWD irstalled)?�Ye� ❑ No ; Site Inspe�tion Checklist: ' All rtems must be checked'Yes'be(or�inspecticn Is consldered complete /�_ , VJas side se�.�er N inspected `rom building io sewer maln? �Yes ❑No Condition: C��'�- Dces side sewer have at least 1%slope from the building to sevrer main? �f Yes ❑Nc Describe: _ Have all building setiver drain connections to the side sewer been idenGfied and locatad? f,k]Yes ❑ No � Have all property sform drainage conreclions to the side sewer been idenGned and located? �']Yes ❑No i H�s property been evaluated for drainzge deficiencies�vith findings communicated fo property o�enzr? �Yes ❑ No � Installation Details: � lNhal type and brand of BNJD�+rs installed at this site (Clean Check BVV�/,Grinder pump, etc.): ��- 1 �--- i VJhere was t:�e device installed (general descriplion,attar,h map)? �v S��t �'N (1�u wz�� ; � Was there any olher sewar or storm drainage work completetl in conjunction with the BWD work? Is so please describe:_ � _Nr��1 � - � Installation Checkllst: � A�e all downspouts and site drainage disconnecte�'from upstream oi lie BWD? �Yes ❑ No Comrnents: Does BWD posiUoning meets minimum slope requirement of>1%? �C�Yes ❑ No Comments: Con BWD be pulled out for inspecGon end mainfenance afler loosening thumb screr�7 �Yes ❑ No Is BWD locked into the proper posiGon and thum6 scre+v 6ghtened? X�Yes ❑ No i Circie the BWD cover. irngation cover(lands pe area)f Uaffic load bearing cnver(drive sudace)1 access hatch(building) ; no co ; Was property o�mer shcvm the lorztion of the installed �WD? �Yes ❑ No Comments: ; Propetty Owner's Signature: Date: i Installer's Signature; � ��a�e: �' � � � - � s ! Revision� 2 1 Monday,September 15,2014 i ;