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� <br /> BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Inslatlalion Company Name and Contact Info:A±Sewer Te�hnolo�ie�l I,G. f888-2?3-76561 _ <br /> Oate backwaler device(BWD)was installed: 20 /23115 Dato Oiis lorm was completod: 02/23I15 <br /> InstaValion Property Ovmer Name and Contacl Inlo: Assemblies QI God Foundation <br /> Property Address: 2605 Baker Ave Fvere.tt WA 8201 <br /> Pre•Instailation Inspoction Checkllsk <br /> All ilems must be checked'Yes'in orde�lor e BWD fo 6e conx'der_•d lor ir.sfallation <br /> Is there a basement or level of the house Ihat is at or n�ar assumed sevrer main elevation7 []Yes ❑No <br /> Are ihe�e fixtures in the house localed below Ihe upslrcam sewer manhole rim elevaUon7[✓] Yes ❑No <br /> Is Ihe side sewer currenHy UNPROTECTED Irom sewcr ba�kups(does nol have a OIYD inslalled)7�Yes ❑No <br /> Site Inspectlon Checkllst: <br /> Ap ifems musl be checked'Yes'befoie inspection is mnsidered camplele <br /> Was side sewcr TV inspected(rom buildir,g to sewer main? �]Yes ❑ No Condilion:�______ __ _ <br /> Does side sewer have at least 1°� siope from Ihe buildino to sewer main7 �✓ Yes ❑ IJo Descnbe <br /> Have ali huilding se���er drain conncctions to Ihe side sewer been identi4ed and IocaleA? ❑Q 1'es ❑No <br /> Have ali property sfomi dr�in=p3 connections to tho side sewer been identifed and localed? []Yes [�No <br /> Has property been eval�ated for diainage deficiencies wilh findings communicated ro property owner? �Q Yes ❑No <br /> Installation Details: <br /> What type anA 6rand of BWD was inslalled at ihis site(Clean Ch�ck BWV,Grinder pump,elc.),�an Check B�V�_ <br /> 1Nhere was Ihe device installed(generel descriplion, aflach map)7 See atloched as buiR _. _ <br /> Was Ihr,re any uther sr.wer or storm drainage work compleled in conjunction tvi�h Ihe ABNlD work7 Is so p:ease descrihe. <br /> --- - ---__-- - -- —_. -- <br /> Installation Checkilst: <br /> Are all dovmspouts and�Ite drainaqe Aisconnected(rom ups�rr.am of thc BWD? n Yes n No Comment;: <br /> floes BWV posil�uning meet minimum slope reyuiremenl ol>1%? n Yes � � No Commenis: <br /> Can BWV bu pulled oul(or inspection and maintenance after loasening Ihumb screvR [��Yes ❑No <br /> Is BWV Icxked into Uie proper position and Ihumb screw ligldened7 (�Yes L J Nn <br /> Circle the ONN cover:iiriyation r.over(landscape area)l lraffic load beanny cover(dnve surlace)I access halch(building) <br /> Was homcowner shown Ihe Incation ol ihc installed A�WD7 [�]Ycs ❑No Commen(s� <br /> Property0wner'sSignature_�'J��l�f��V� _____ Date: <br /> Walt r^�.;.`,,.� - <br /> Inslaller'sSignature� __._-�_-«-;�-�• Datc: � ��. /� <br /> Ncvlslon-7 1 Thuraddy,Octo6cr OZ, 2U34 <br />