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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info: A+ Sewer Technologies I-I-C. (888-213-7656) <br />Dale backwater device (BWD) was installed: O i 14115 Dale this form was completed; 07/14/15 <br />Installation Property Owner Name and Contact Info: Kristine Washburn <br />Property Address: 1808 Lombard Ave 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 abasement or level of the house that Is at or near assumed sewer main elevation? ❑✓ Yes LiNo <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? ❑✓ Yes ❑ No <br />Is the side sewer r-rently UNPROTECTED from sewer backups (does not have a BWD installed)? ❑✓ Yes ❑ 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 ❑ No Condition: <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? 2 Yes ❑ t' <br />Have all properly storm drainage connections to the side sewer been identified and located? ❑✓ Yes []No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? ❑,/ Yes ❑ 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, allach map)? See attached as built <br />Was there any other sewer or storm drainage work completed in conjunction with the A8WD 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 BWV positioning meet minimum slope requirement of >1%? ❑a Yes ❑ No Comments: <br />Can BWV be pulled out for inspection and maintenance after loosening thumb screw? Q Yes ❑ No <br />Is BWV locked into the proper position and thumb screw lightened? © Yes ❑ No <br />Circle the BWV cover. irrigation cover (landscape area) I traffic load bearing cover (drive surface) i access hatch (building) <br />Was homeowner shown the location of the installed ABB/WD? []Yes ❑ No Comments: <br />Property Owner's Signature: <br />g Walt o� <br />Installers Si nature: ._,..,� <br />Dale: <br />Date: <br />Revision: 2 1 Thursday, October 02, 2014 <br />