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BACKWATER PREVENTION DEVICE FINAL <br /> 04.77. <br /> INSTALLATION CHECKLIST <br /> Installation Company Name and Contact Info: CJ'S PLUMBING&SERVICE LLC 360-691-5159 <br /> Date Backwater Prevention device (BWD)was installed//O// ( Date this form was completed:d —/1--/ <br /> Installation Property Owner Name and Contact Info: g fl r,4 - 2g C/ �e., /% <br /> Property Address: 2 re) f TO 4,14 /ifcfr , rt4PA7 rI--- <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 ❑ No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation? Yes ❑ No <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)? ❑Yes ❑ No <br /> Site Inspection Checklist: <br /> All items must be checked Yes'before inspection is considered complete Was side sewer TV inspected from building to sewer main? ®Yes ❑ No Condition:0 Jsn� <br /> Warn &INTL <br /> d` <br /> Does side sewer have at least 1% slope from the building to sewer main? 0 Yes ❑ No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? on Yes ❑ No <br /> Have all property storm drainage connections to the side sewer been identified and located? X Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 51 Yes ❑ No <br /> Installation Details: <br /> What type and brand of BWD was installed at this site (Clean Check BWV, Grinder pump, etc.): Ate Sias <br /> Where was the device installed (general description, attach map)? -cipI- c roe SI Lk D c ` out <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work? Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? Z Yes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? [IYes ❑ No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? [ 'Yes ❑ No <br /> Is BWD locked into the proper position and thumb screw tightened? VI'Yes ❑ No <br /> Circle the BWD cover: irrigation cover(landscape area)I traffic load bearing cover(drive surface)I access hatch (building) <br /> Was property owner shown the ocation of the i stalled BWD? [ Yes ❑ No Comments: <br /> ��Property Owner's Sign Date: �`l( '''/ <br /> Installer's Signature: Date: CR I(r j5 <br /> Revision:2 1 Friday,September 12, 2014 <br />