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6ACKWATER PREVENTION DEViCE FINAL <br /> ,�, INSTALLATIOt� �HECKLIST <br /> Inslallalion Company Name and Contacl Inio.�S (����'N�n�_� e���n ��C <br /> Cate Backwater Prevention dev;ce(BIND)was installed: N 1 1� Dale ihis form e�as completed:`r��� ��V <br /> Installatlon Properly Owne:Name and Conlacl Info: V�i(� �M��-� � � ic`��1 1 �� , �MQ�" <br /> PropertyAd�r=ss: IZ.I� liU\d�J\�L S-� ��"�� W� <br /> Pre•Installation Inspection Checklist: <br /> All items must be checked 'Yes'in o�der�or a BVVD to be considered tor inslalfation <br /> Is ihere a basement or level o(ihe house thal is at or near assumed ser+er main elevalion?[�Yes ❑No <br /> Are there fixtures in Ihe house located 6elo�ti�the upstream sewer manhole rim elevation? �Yes ❑No <br /> Is the sic.e sevie�currently UNPROTECTED from se���er backups(does nol ha��e a BWD installed)7�Yes ❑No <br /> Site Inspection Checklist: <br /> AI�items rnust 6e checked'Yes'before inspection is considered complete <br /> Was side se�ver TV inspecled from building to se��:er main? � Yes ❑ No Condilion: ��I� Ca,�NE K�E 9o� <br /> Does side se�.ti�er have at leasl t°�o slope irom lhe 6uiiding to se��er ma'n7 [�Yes ❑No Describe <br /> Have all buildmg sewer drain connectiors to the side se�ver 6een idenlifiad and Iocated? �Yes ❑ No <br /> Have all property storm drainage conneclions to the side sewer been identified and locafed7 �( Yes ❑ No <br /> Has property be^n evaluated for drai��age deficiencies�vith fndinns communicated to properiy ovmer? �Yes ❑ No <br /> Inscallalion Details: <br /> VVnat lype and brand o(BN�D was installed at this site(Clean Check BWV, Grinder pump, elc.):RU���w�_ <br /> Where was Ihe device insfalled (general description, atizch map)? 0:,4� St.� �Lcx�-c t.s��.l� ��cz,S�+ai� <br /> N'as lhere a'�y other sewer or slorm dr3inage work completed in conjunction avith the BWD work? Is so please descrihe: NO <br /> Installation Checklist: <br /> Are all do�vnspouts and site drainage disconnected irom upstream of�he B4VD? `Ij�Yes ❑ No Comments: <br /> Does BWD posilioni�g meets minimum slope requirement of>1%? '�Yes ❑ No Comments <br /> Can BWD be pulled out(or inspeclion ar.d maintenance after loosening thumb scree�7 ❑Yes ❑No <br /> Is BWD locked in�o lhe proper posilion and lhumb scree�tightened? �Yes ❑ No <br /> Cirde the BWD cover, irrigation cover(landscape�rea)I iraHic load �earing cover(drive surlace)1 access hatch(bui!ding) <br /> INas property oumei shown lhe location of the installed BWD� �Yes ❑ No Comments: <br /> Property O�vner s SignaWre i� � ����n � /�h��' Date: �'N �� <br /> Inslaller's Signatur Date: �`�" ��-- !� <br /> Re��sion:2 1 friday,September 12,2014 <br />