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4,�. BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and CoNact Info SEATTLE DRAIN SERVICE <br /> Date Backe�ater Prevention device(BWD)was installed: Date this form�vas compleled: <br /> Instailalior Property Owner Namc and Contact Inio. y,��=--]-C'' L.. G'•� <br /> Property Address - EVERETT WA 9820�_;��L_��C9�'�U� � <br /> Pre•Installation Inspection Checklist: <br /> All ifems musf be checked'Yes'in order loi a BWD t�be consrdered for insfallafion <br /> Is ihere a basement or level of the house that is at or near assumed se�ver main eievation7 Ye Wo <br /> Are there lixtures in the house located belo�v th? upstream sev�er manhole rim elevation? es No <br /> Is ihe side sevaer currently UtJPROTECTED from sev:er backups (does not have a BWD installed ? a(es No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes before inspecfion is considered compiete <br /> lh�as side sev.�er TV inspected irom building to se�+rer main o Yes o Condition: <br /> Does side se�ver have at least 19b slope (rom the building to sevrer mein o Yes I I No Describe: <br /> Have all building sev.�er drain connections to the side se�ver been identi(ied and locate , �fes i No <br /> Have all property storm drainage connections to the side se�ver been identified and locate n Ye o No <br /> Has property been evalualed for drainage deticiencies�vith (indings ccmmunicaled lo property o�vner o Yes I I No <br /> '. Installation Details: �� � � (� <br /> lNhat type and brand o(B4VD�vas installed at this site(Clean Check B�WV,Grinder pump, etc.): ��C�C1�i1"C�4` � <br /> Where was ti^device installed(general description,allach map)? \�G� �a��p yn���.1 1,5��4�.�c(1 <br /> � <br /> Was Ihere any olher sewer or slorm drainage work completed in coajunction�vith the BWD work? Is so please describe: <br /> ��v <br /> Installation Checklist: <br /> Are ail do�vnspouts and site drainage disconnected from upsiream oi te BWD7 i es o Commenis <br /> Does BWD posilioning meels minimum slope requirement ot>1%? I�Yes No Commenis: ______ <br /> Can BWD be pulled out lor inspection and mainlenaoce after loosening Ihu b scre�v7 r. Yes o <br /> Is BWD locked into the proper position and ihumb screv.� tightened? o Ye ❑ No <br /> Circle fhe BWD cover� alion c'over(landscape area traffic load bearing cover(drive surface) I access hatch (building) <br /> Was property owner shown Ihe loca�ion of the installed BW n Yes I No Commenis: <br /> � t ��i <br /> �7� p����,i .� � , r� .� <br /> Property O�vner's Signature y � _' � Date: � � z-U�S <br /> Installers Signature:`�G V�� 'll1-C� ' �ate: ��"�-)�� <br /> � <br /> Revision 2 1 Monday, September 15, 2014 <br />