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1!!!!! <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:A+ Sewer Technologies LLC. (888-213-7656) <br /> Date backwater device(BWD)was installed: 08/06/15 Date this form was completed: 08/06/15 <br /> Installation Property Owner Name and Contact Info: Annabelle Rockwood <br /> Property Address: 2 i)Z,Vlaple St Everett WA 98201 <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'in order for a BWD to be considered for installation <br /> Is there a basement or level of the house that is at or near assumed sewer main elevation?Q Yes 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? ✓❑Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?Ei Yes 0 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? 0 Yes 0 No Condition: Blockage @ 32 feet <br /> Does side sewer have at least 1%slope from the building to sewer main? [✓]Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ❑✓ Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? ❑✓ Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? D Yes 0 No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site(Clean Check BWV, Grinder pump,etc.): Clean Check BWV <br /> Where was the device installed (general description, attach map)? See attached as built <br /> Was there any other sewer or storm drainage work completed in conjunction with the ABWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? ❑✓ Yes 0 No Comments: <br /> Does BWV positioning meet minimum slope requirement of>1%? ❑✓ Yes 0 No Comments: <br /> Can BWV be pulled out for inspection and maintenance after loosening thumb screw? 0 Yes 0 No <br /> Is BWV locked into the proper position and thumb screw tightened? 0 Yes ❑ No <br /> Circle the BWV cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was homeowner shown the location of the installed ABWD? Ij Yes 0 No Comments: <br /> Property Owner's Signature: / Date: 4 J <br /> 0.9884.9000 <br /> Installer's Signature: DN,�Wa_M.- Date: <br /> Dale:2015.92.1E 09;10:02-OB'(IV <br /> Revision:2 1 Thursday,October 02,2014 <br />