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1 <br /> American Septic&Sewer 425-252.5874 p,02 <br /> 4BACKWATER PREVENTION DEVICE FINAL <br /> 4577 INSTALLATION CHECKLIST <br /> Installation company Name and Contact Info '+' arre 24!.464 <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed:, <br /> Installation Property Owner Name and cam <br /> Contact Info:�(���"-� � C, <br /> Property Address t9= t�` F Com' Wo-A-0 f <br /> Pre-Installation Inspection Checklist: <br /> All items must be checked'Yes'lit order fora BWD to be considered fpr Installation t <br /> Is there a basarneht or level of the house that is at or neer assumed sewer main elevation?49-Yes [l No <br /> Are there fixtures in the hoLne located below the upsiream sewer manhole rim elevation?[;�Yas ❑No <br /> Is the side sewer currenhy UNPROTECTED from sewer backups(does not have a I3WD Instal!ed)?[Iyes ❑No a <br /> site Inspection checklist: <br /> f <br /> All items must be chocked'Yes'before inspection is considered complele <br /> Was side sewer TV inspected from building to sewer main? C�s d No Condition: Ch <br /> Does side sewer have at least 1%slope from the building to sewer mein? P:Tes ❑No Describe: <br /> Have all building sewer drain connections to the side sewer been Identified and located? Cpl-yes D No 3 <br /> Have all property storm drainage conneotions to the side sewer been identified and located? 41,-Yes ❑No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? [ ,Yes ❑ No <br /> ( <br /> Installation Details: <br /> What type end brand of SM was Installed at this site(Clean Check M,Grinder pump,etc.); , x <br /> Where was the device installed(general description,attach map)7 �U <br /> Was there any othar Sewer or storm drainage work camplotad in conjunction with the BWD work?Is so please describe: <br /> Installation Checklist: <br /> Are all downspouts and site drainage dlsoonnected from upstream of the BLVD? *Ixas []No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%?—e*% ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? GYe9 ❑No <br /> Is BWD iocked into the propos position and thumb screw tightened? [ Yea r7No <br /> QrGle the BWD cov ;inigatio uer ndscape area)/traffic load bearing cover(drive surface)/access hatch(bullding) <br /> l <br /> Was property owner shown the location of the installed BWD?P-fes []NO Comments: <br /> 3 <br /> Property Owner's Signatule: Date; L <br /> Inatalier's Signature. Date: <br /> a <br /> Revision:2 1 Friday,September 12,Zola <br /> I <br /> i <br /> r <br /> 5 <br /> S <br /> S <br />