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BACKWATER PREVENTION DEVICE FINAL <br />4 INSTALLATION CHECKLIST <br />Installation Company Name and Contact Info. A+ Sewer Technologies LLC. (888-� <br />Date backwater device (BWD) was installed: Date this form was <br />Installation Property Owner Name and Contact Info: THCrman Q bery (425)765_6; <br />Property Address: 3414 Oakes Ave Everett WA 98201 <br />Pre -Installation Inspection Checklist: <br />All items must be checked 'Yes' in order for a LIM to be considered for installation <br />Is there a basement or level of the house that is at or near assumed sewer main elevation? ❑ Yes ❑ No <br />Are there fixtures in the house located below the upstream sewer manhole rim elevation? 0 Yes ❑ No <br />Is the side sever currently UNPROTECTED from sewer backups (does not have a BWD installed)? ❑✓ Yes L No <br />Site Inspection Checklist: <br />All items must be checked 'Yes' before inspection is considered complete <br />Was side sewer TV inspected from tuilding to sewer main? ❑Q Yes ❑ No Condition: <br />Does side sewer have at least 1 % slope from the building to sewer main? 2 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 ❑ No <br />Has property been evaluated for drainage deficiencies with findings communicated to property owner? Q 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, attach map)? See attached as built <br />Was there any other sewer or storm drainage work comple!ed ;n conjunction with the ABWD work? Is so please dascribe: <br />Installation Checklist: <br />Are all downspouts and site drainage disconnected from upstream of the BWD? (7 Yes ❑ No Comments: <br />Does BWV positioning meet minimum slope requirement of >1 %? [aYes ❑ No Comments: <br />Can BWV be pulled out for inspection and maintenance after loosening thumb strewn [] Yes ❑ No <br />Is BINV locked into the proper position and thumbscrew tightened? ❑� Yes []No <br />Circle the BWV cover. irrigation rover (landscape area) I traffic load bearing cover (drive surface) I access hatch (building) <br />Was homeowner shown the location of the installed ABWD? [k] Yes ❑ No Comments: <br />Property Owner's Signature:! 1 �ti �u, 1.��� Date: <br />y <br />Installer's Signature: Walt c x Date:% <br />Revision: 2 1 Thursday, October 02, 2014 <br />