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4,,, BACKWATER PREVEN�ION DEVICE FINAL <br />INSTALLAYION CHECKLIST <br />inslallation Company Name and Contac! Info: SEATTLE DRAIN sERVICE <br />Date Backwater Prevenlion device (BWD) �v2s inslalled: _ Date ihis form v�as completed� <br />Installation Property Ovmer Name and Contact In(o: oaN HORINE _ <br />PropertyAddress: 3521 �oMeARD avE E�JERETT WA 98201_ <br />Pre•Installation Inspection Checklist: <br />A!I items must be checked 'Yes' in order for a BWD to be considered (or installation <br />Is ihere a basement or level of ihe house that is at or near assumed se�ver main elevation? � Ye �Jo <br />Are there (ixlures in the house localed belovi the upslream '�wer manhole rim elevati ? e n No <br />Is the side see:er currenlly UNPROTECTED from se�ver backups (does not have a BWD installed . Cles � No <br />Site inspection Ctiecklist: <br />All i�ems must be checked'Yes 6e�ore inspecfion is conside —compfefe <br />Vdas side sewer TV insper;ed irom building to sewer main. u Ye o Condition <br />Does side sewer have at 12ds1 15o siope (rom the building to sewer m�?� Ye I I No Describe: <br />Have all building sewer drain connections to lhe sitle se�ver been idenlified and locat 7 CNes i No <br />Have all property storm drainage connections to the side sewer been idenlified and loca ed'rn Yes o No <br />Has property been evalualed for drainage de(iciencies wilh fintlings ccmmunicated to property o�vner? u Yes I No <br />ilnstallation Details: / �� <br />What type and brand of BWD �vas inslalled at Ihis sile (Clean Check BWV, Grinder pump, elc.): �����y�� ._ `7' / <br />';Uhera was ihe device insialled (general descnption, attach map)? �C'y���.�;> �'�(,lL�-t�.,L.1'� ��C� <br />lNas there any olher sewer or slorm tlrainage �vork completed in conjunction �vith lhe BWD v:ork? Is so please describe: <br />Installation Chocklist: <br />Are all downspouts and site drainage disconnectetl from upslream of le BWD7 i �s_�iljn Comments: __ <br />Does BWD posilioninc� meets minimum slope requirement of >1%a? I Yes o o Commenis <br />Can BWD be pulled out for inspeclion and mainlenance afler loosening lhumb screw7 r Yes o <br />Is BWD Iocked into the ro er osilion and Ihumb sr.reva tighlened? Y�., No <br />Circle the BUdD cover: irri atry`n cover (landscape ar� I traff c load bearing cover (drive suriace) i access halch (building) <br />Was properly owner shown the location of the installed BWD7 n Yes I I No Commenls._ _ _ <br />Properly0wnersSi re;�lla1'�II.0 Dale: J �5 <br />� , r� <br />Inslaller's Signature: �1�1/Ybu Date: ,�__—. <br />Revision 2 1 Monday, September 15, 2014 <br />