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joilp <br /> 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: 10/2/14 Date this form was completed: 10/2/14 <br /> Installation Property Owner Name and Contact Info: Bill Franz(425-754-5951) <br /> Property Address: 1401 Rockefeller <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?❑Q Yes 0 No <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?0 Yes 0 No <br /> Is the side sewer currently UNPROTECTED from sewer backups(does not have a BWD installed)?0 Yes ❑ 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? 0 Yes ❑ No Condition: <br /> Does side sewer have at least 1%slope from the building to sewer main? 0 Yes 0 No Describe: <br /> Have all building sewer drain connections to the side sewer been identified and located? ❑■ 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? 0 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 BVW <br /> Where was the device installed (general description,attach map)? North side of property, center of structure <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? 0 Yes ❑ No Comments: <br /> Does BWV positioning meet minimum slope requirement of>1%? 0 Yes ❑ No Comments: <br /> Can BWV be pulled out for inspection and maintenance after loosening thumb screw? 0 Yes 0 No <br /> Is BWV locked into the proper position and thumb screw tightened? 0 Yes 0 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 ABWD? 0 Yes 0 No Comments: <br /> Property Owner's Signature: Date: (0 9/ / <br /> 4---- <br /> Installer's Signature: Date: —0-20/4/- <br /> Revision:n:2 1 Thursday,October 02,2014 <br />