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BACKWATER PREVENTION DEVICE FINAL <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info:A+ Sewer Technologies LLC. (888-213-7656) <br /> Date backwater device(BWD)was installed: 01/20/15 Date this form was completed: 01/20/15 <br /> Installation Property Owner Name and Contact Info: Cynthia Gaub 253 232-6946 <br /> Property Address: 1617 Fulton St Everett WA 98201 <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked Yes'in order for a BWD 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 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?IZI Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)? ❑✓ Yes 0 No <br /> Site Inspection Checklist: <br /> All items must be checked Yes'before inspection is considered complete <br /> Was side sewer TV inspected from building to sewer main? ❑✓ Yes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? ®Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? 0 Yes ❑No <br /> Have all property storm drainage connections to the side sewer been identified and located? 0 Yes 0 No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? ✓❑Yes 0 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 completed in conjunction with the ABWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? ❑Yes 0 No Comments: N/A <br /> Does BWV positioning meet minimum slope requirement of>1%? ❑✓ Yes 0 No Comments: <br /> Can BWV be pulled out for inspection and maintenance after loosening thumb screw? ❑✓ Yes ❑No <br /> Is BWV locked into the proper position and thumb screw tightened? ❑✓ Yes ❑ No <br /> Circle the BWV cover: irrigation cover(landscape area)/traffic load bearing cover(drive surface)/access hatch (building) <br /> Was homeowner shown the location of the installed 'BWD? ❑✓ Yes ❑ No Comments: <br /> ' t) <br /> Property Owner's Signature Date. <br /> Installer's Signature: Walt pate:2015.01.2016 Date: <br /> Revision:2 1 Thursday,October 02,2014 <br />