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�3AC1(1�AT�R PREVENTBOfV DEVICE �INAL I <br /> � <br /> � �6�5'TALLATlON CFIECKLiST j <br /> i <br /> � <br /> _____ � <br /> Installation Company Name and Contact Into: M UGn ����,n1j�� ��2 f� 7(00 �3�� ! <br /> Date Baclnvater Prev, �tion device{BVJD)was ins�elied: `� ' �k"� S Dale this torm���as compleled: `a -�Fr'� S <br /> P �Y ^^ �r. ; <br /> Installation Pro e Owner Name and Contact Into: D � cc���t/c� , <br /> c� s�' ' <br />^�< � Property Address: 1 � a� (r�z.� � �'v'�� I <br />:. <br /> � <br /> Pre•Installation Inspection Checklist: � <br /> .411 items must be checked'Yes'rn order for o 8WD l0 6s considered far installefion ; <br /> i <br /> Is there a basement or level oi lhe house ihat is at or near assumed seH�er main elevation?�(Yes ❑No • <br /> i <br /> Are there tixtures in;�ie house located beio�+�the upstream sevrer manhole rim elevation?�Yes ❑No I <br /> Is Ihe side se�•�er currenUy UNPROTECTED from sewer backups (does nol have a BIND insialled)?�Yes ❑No � <br /> Site Inspeotion Checklist: � <br /> All items must 6e checkea'Yes'before inspection Is considered complefe � <br /> !Nas side sewer TV inspected from buiiding to se��aer main7 �Yes ❑No Condition: �4J�'�'"L �"""'�'�`� � <br /> Dces side se�ver have at least 1%slope from tlie building to sev+er main? �Yes ❑ No Describe: ? <br /> Have all building sewer drain conneclions lo ihe side so�+�er been idenlified and located? �Yes ❑ No <br /> Have all properry slorm drainage connections te lhe side seveer been identified and located? �Yes ❑ No i <br /> Has property been ovaluated tor drainage deficiencies vr'th findings communicated to property owner? �Yes ❑ No i <br /> InstallaGon Details: I <br /> Wfiaf type and brand of BWD was installed at this site(Clean Check BWV,Gdnder pump,etc.): «��`-{ � ��-z� �'*-�Z ; <br /> l':'here vras ihe device installed(generai descrip0on, attach map)? 1,<<e�-�..+��' ti-� L.c•••���'�( <�-•� ; <br /> VJas there any othar sewer or storm drainage vrork compluted in conjunclion a�ith the BIND v�ork?Is so please describe�_ i <br /> n�A ; <br /> Installalion Checklist: � <br /> r1�e all downspouts and sile drainage disconnected from upstream of the BIND? �Yes ❑No Comments: <br /> ,oes BIND positioNng meets minlmum slope requirement o`>1%? �Yes ❑ No Commenls: � <br /> Can BVJD bz pulled oul tor inspectlon and maintenance aRer loosening thumb screw? ❑Yes ❑No � <br /> Is BWD locked inlo the proper position and thumb screw t�ghtened? ❑Yes ❑�o ? <br /> Circle the BWD cover:irrigation co��er(landscape area)I lraffic load bearing cover(drive surface)1 access hatch(building) N� i <br /> Was property ovmer shown the location of the installed BWD? �]Yes ❑No Comments: i <br /> ( <br /> Property Otivners Signature: Date: � <br /> Insfallers Signature: �� �'-- Date: `� ' I ��! � ` <br /> Revision:2 1 Monday,September 15,2014 , <br /> � <br /> I <br />