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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installalion Company Name and Coniact Info:A+ Sewer Technolopies LLC j688-213 Z 561 <br /> Date backwater device(BWD)was inslalied: Ot/08115 Dale this form��as completed: 01l09115 <br /> installation Property O�mer Name and Contact In(o: Th�ma�r���Pllo <br /> Property Address: 1620 Wetmore Everett WA 98201 _._, <br /> Pre•Installation Inspection Checklist: <br /> Ail ifems mu:t be checked'Yes'in order for a BWD to be consrdered lor installation <br /> Is there a basement or level of the house lhal is at or near assumed sewer main elevalion? 0 Yes ❑No <br /> Are there fixtures in the house located below ihe upsiream sewer manhole rim elevalion?�✓ Yes ❑No <br /> Is the side sewer currenlly UNPROTECTED irom sewer backups(does not have a BWD instailed�?❑✓ Yes ❑No <br /> Site Inspection Checklist: <br /> All items must be checked'Yes'before inspection is considered complete <br /> Was side se���er TV inspecled(rom building to se�ver main? ❑✓ Yes ❑No Condition: <br /> Does side sewer have at least 1%slope irom the building to sewer main? ❑� Yes ❑ No Describe: <br /> Have all building sewer drain conneclions to the side sewer been identified and localedl ❑� Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and localed? 0 Yes ❑No <br /> Has property been evaluatad for drainage deficiencies�vith findings communicaled to property o�vner? ✓❑Yes ❑ No <br /> installation Details: ! <br /> What type and brand o(BWD was inslalled at this site(Clean Check BWV,Grinder pump,efc.): Clean CI ier.k <br /> Where was ihe device installed(general description,atlaeh map)? 5'6" deen <br /> `� "� .,P p <br /> Was there any olher se�ver or slorm drainage work completed in conjunc6on wilh the ABWD work7 Is so please describe: � <br /> Installation Checkliat: <br /> Are all downspouls and site drainage disconnected(rom upsiream of the BWD? ❑Yes ❑J No Comments: <br /> Does BWV positioning meet minimum slope requiremenl of>t°h? �]Yes ❑No Commenls: <br /> Can BWV be pulled oul for inspeclion and maintenance after loosening thumb screw? 0 Yes ❑No I <br /> Is BWV locked into the proper position and ihumb screw tightened? ❑� Yes ❑No j <br /> Circle the BWV cover:irrigation cover(landscape area)I traffic load bearing cover(drive sudace)1 access hatch(building) <br /> Was homeowner shown the locatio of Ihe inslalled ABWD7 �Yes ❑ No Comments: <br /> `� ' �/� �/(� <br /> Property Owner's Signature 1 �-- � Dale: <br /> WB�� `�"`� Da�e: l/12/2015 <br /> Inslaller's Signature: """'-"�� <br /> Revision: 2 1 Thursday,October 02, 2014 <br />