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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:A+ Sewer Technoloqie� LL . (888-213-7656) <br /> Date back�vater device(BWD)was Installed: 02/26/15 Date this form was�ompleted: 02/26/15 <br /> Installation Properly Owner Name and Conlact Info: Matt Fre�d (360)460-2405 <br /> Property Address: 1531 Wetmore Ave Everett WA 98201 <br /> Pre-Installation Inspection Checklist: <br /> Al!flems must be checked'Yes'in o�der for a BWD lo be considered lor installation <br /> Is Ihere a basement or level of ihe house Ihal is al or near assumed sewer main elevation?1]Yes ❑No <br /> Are lhere f xtures in Ihe house looated belovr the upsiream sewer manhole rim elevalion?Q✓ Yes ❑No <br /> Is the side se�ver currently UNPROTECTED from sewer backups(does not have a BWD inslalled)?[]Yes ❑No <br /> Site Inspection Checklist: <br /> All ifems must be checked'Yes'belore inspecfion is consrdered camplete <br /> Was side sewer TV inspected(rom building to sewer main7 0 Yes ❑No Condition: <br /> Does side sewer have at least 1%slope from the building to se�ver main? 0 Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been idenlified a�d located2 ❑Q Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identif ed and located? �Yes ❑No <br /> Has property been evaluated for draina9e deficiencies with findings communicaled to property owner? �Yes ❑No <br /> Installation Details: <br /> Whal type and brand of BWD was inslalled at Ihis sile(Clean Check BWV,Grinder pump,etc.):SJean Check BWV <br /> Where was ihe device installed(general descriplion,attach map)? See attached as built <br /> Was ihere any other sewer or storm drainage work compleled in conjunclion with ihe ABWD work?Is so please describe: <br /> Installallon Checklist: <br /> Are all dovmspouts and site drainage disconnected(rom upslream o(Ihe BINJ? [] Yes ❑No Commenis: <br /> Daes BWV posilioning meet minimum slope requiremen�of>1%? []Yes ❑ No Commenls: <br /> Can BVJV be pulled out for inspeclion and mainlenanee afier loosening ihumb screm? 0 Yes ❑No <br /> Is BWV locked inlo ihe proper position and lhumb screw tightened? [✓_�Yes ❑No � <br /> Circle Ihe BWV cover.ircigaGon cover(landscape area)1 Ua(fic load bearing cover(drive surtace)/access hatch(buitding) <br /> Was homeowner shown the location of the inslalled ABWD7 []Yes ❑No Commenls: <br /> Property O�vner's Signature:�//l��!/(��� Date: �Z—=4- '�� <br /> Walt ;."`".�r'.., <br /> _._�.W_..,e <br /> Installer's Signature: �..„,�,��„� Date:�—Zl%' S <br /> Revision:2 1 Thursday,October 02,2D14 <br />