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1 <br /> � <br /> BACKWATER PREVENTION DEVICE FINAL � <br /> INSTALLATION GHECKLIST I <br /> ! <br /> ,��c,�r►c�zn �.z�� <br /> ; G ^F `3id� S�y�:�':/'! L LG � <br /> •T_ rr n� „�, iii � �v]! <br /> Installation Company Name and Contact Inio:.� � rc�c.� �-, � j)'--�`�� �fj "'T''�� �'� ����-'�:� � <br /> Dzte Backwater Preveniion device(BWD)eras installed: .r � .��Date this form�vas completed: S `J i <br /> ^ �1� _J � � <br /> Installation Property Owner Name and Contact Info:� :� P�� �t a� � ��1� ) ; <br /> �� r � � ,, , f� � <br /> PropertyAddress� ,.�-t.=�—�'�G�� �-y�,�"o.t ��- e �UF���C�' ��.F����� �' � <br /> I <br /> Pre•Installation Inspection Cliecklist: � <br /> Af!items must 6e checked'Yes'm order for a BWD to be considered for instalfafion <br /> Is there a basement or ievel of the house that is at or near assumed sewer main ele��ation?�Yes ❑ Ne � <br /> Are there fixtures in the house lo�ated 6elove the upstream sewer manhoie rim elevalion?�'Yes ❑ No � <br /> Is fhe side sewer currently UNPROTECTED from sev�er backups (does not have a BWD ins(alled)?� Yes ❑ No � <br /> Site Inspection Checklist: � <br /> AN items must be checked'Yes'before inspectron is considered r.omplete ' <br /> VVas side sevrer TV inspected from building to seveer main? [�Yes ❑No Condition:�(� � <br /> Does side sewer have at least 1%slope from the building to sewer main? �}1'es ❑ No Describe: ; <br /> Have all building se�ver drain connections to the side sevrer Ceen identified and located? �Yes ❑ No � <br /> Have all property storm drainage conr��ctions to the side sewer been identified and located? �Xes ❑ No � <br /> Has property been evaivated for drainage deficiencies�.�ith findings communicated lo property owner? �]�Yes ❑ No ; <br /> Installation Details: � <br /> What type and brand of BIND�vas installed at Ihis sile(Clean Check BIN1�, Grinder pump,etC.): '' � �� � <br /> Where was the device insta(led (general descripiion,atta�h map)7 �C-'.P �j��'�'G.r�itti�/�S_ ��(� ; <br /> Was there any olher sewer or storm drainage�vork completetl in conjunc�tion with the BWO�vork? Is so ple�se describe:_ ; <br /> 1�1�)YL(% GL�'� �1"Z{�I �-t%�y�(/' _ - / � � <br /> Instaliation Checklist: � <br /> Are all downspouls and site drainage disconnecled(rom upstream of the E3VyD? �'Yes ❑No Commenls ` <br /> Does BWD pasi(ioning meets minimum slope requirement of=1%7 ��1'es ❑ No Comments: ' <br /> � <br /> Can BIND be pulled out for inspection and maintenznce aiter loosening thumb scre�v? �:Y'es ❑ No ; <br /> Is BWD locked into lhe proper position and thumb sc�e�v lightened? �Yes ❑ �o i <br /> Cirde the Bl4�D cov�irrigation.cover(landscape area) I tra(fc loatl bearing cover(drive surface)I access hatch (building) ' <br /> Was property nwner shown Ihe loc 'on of thej� talled BWD? �Yes ❑ No Commenls: i <br /> U� / i <br /> Pro,�erty Owner's Signature: _ Date: 5 l� / S � <br /> i <br /> �' <br /> Installer's Signature: / - ° � Date: � � _ � <br /> / � <br /> Revision:2 1 Friday,Sepiember 12, 2014 i <br /> I <br />