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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLY TISN CHECKLIST <br /> Installation Company Name and Contact Info: <br /> Date Backwater Prevention device (BIND) was installed: <br /> Date this form was completed: <br /> Installation Property Owner Name and Contact Info: <br /> Property Address: <br /> Pre-Installation Inspection Checklist; <br /> All items must be checked'Yes'in order for a BWD t0 be considered for i,nstaflat�en <br /> is there a basement or level of the house that is at or near assumed sewer main elevation? Ki Yes LJ No <br /> Are there fixtures n the house located below the upstream sewer manhc'e rim elevation? Yes (j No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BIA/D installed)? ? Yes L ii No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? Yes i7 No Condition; . <br /> Does side sewer have at least 1%slope from the building to sewer main? i Yes `- No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ZtYes i j No <br /> Have ail property storm drainage connections to the side sewer been identified located?ed and <br /> -t gi Yes n No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? M Yes Li No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): c--\ea./v-1 <br /> Where was the device installed (general description, attach map)? OUAS 1 di, irl,.Ol2 <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> Installation Checklist: .. <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? � Yes No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%%%? `k <br /> Yes El No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? NJ Yes Li No <br /> Is BWD locked into the proper positi nd-` u screw tightened? YeJ <br /> � Li No <br /> Circle the BWD cover: irrigation cover(landscape area <br /> p � afi€ic load bearing cover(drive surface)/access hatch(building) <br /> Was property owner shown the location of the installed BWD? Ye..s r--L_1 Comments: <br /> No <br /> fyt Property Owner's Signature: G ,ww / : <br /> � ,� Date: � <br /> Installer's 5ignafu, � L % '- <br /> Date: <br /> Revision:2 1 Friday,September 12, 2014 <br />