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BACKWATER PREVENTION DEVICE FINAL <br /> IN5TALLATION CHECKLIST <br /> Installation Company Name and Contact Info:A+ Sewer ech o s Ll C. (888-7.13-76561 <br /> Dale backwaler device(BWD)v�as instalied: S 8 2vi5 Date this form was completed: `'�� 2a�5 <br /> installalion Property O�vner Name and Contact In(o: Colleen Gamm�n <br /> Properly Address: 1832 We[mare Ave Everett WA 98201 _ <br /> Pre•Inetallation Inspection Checklist: <br /> All ifems must be checked 'Yes'in order�or a BWD fo 6e considered tor instalfation <br /> Is there a basement or level of ihe house that is at or near assumed sewer main elevation? ❑✓ Yes ❑No <br /> Are ihere fixlures in the house iocated below the upsheam se�ver manhoie rim elevation?G Yes ❑Mo <br /> Is the side se�ver currenUy UNPROTECTED from sewer backup,(does not have a BWD installed)? �Yes ❑No <br /> Site Inspection Checklist: <br /> All ilems must be checked 'Yes'6e(ore inspection is considered compfete <br /> V��as side sewer TV inspecled irem buildina to sewer main? �✓ Yes ❑No Condilion: <br /> Dces side se�ver have al least 1°/a siope from ihe building to sewer main? ❑� Yes ❑No Describe: <br /> HavF all builtling sew�er drain conneclions to the side sewer heen identifad and located? ❑� Yes ❑ No <br /> Have all property storm drainage conneclions to the side sewer been idenlified and located? QQ Yes ❑ No <br /> Has property been evalualed(or drainage deficiencies with findings commimicated to property owne� �Yes ❑No <br /> Inslallation Details: <br /> What type and hrand o(BWD was installed at ihis site(Clean Check BWV, Grinder pump,etc.�: Gean Chec:k RWV <br /> VVhere was ihe device instalied(general description, atlach map)? See attached ��s built <br /> N'as ihere any other sewer or storm drainage work completed in conjunction wilh lhe ABWD work? Is so please describe <br /> Installation Checklist: / <br /> Are all downspouls and site drainage disconnected from upstream of the BWD? Q"Yes ❑No Comments: <br /> Does BWV posihoning mcet minimum slope requirement o(=1°0? Yes ❑No Com�ments: <br /> Can BWV be pulled oul for inspection and maintenance after loosening thu b screw7 �"Yes ❑No <br /> Is BWV locked into ihe ro er osilion and ihumb scre�v tightened? Yes ❑ No <br /> Circle Ihe BWV cov : irrigation cover landscape area)1 iraffic la�aring cover(drive suriace)/access hatch (building) <br /> Was horneowner shown lhe lo alion oi ihe installed ABWD? es ❑No i.onimenis: <br /> Property Owner's Signature: � Date: .f 8 <br /> u P�Nh�'r <br /> Installer's Signature; �a�t ~�;,,-� Date: � �!� <br /> Revision:2 1 Thursday,October 02, 2014 <br />