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� <br /> �ACKi�I����t ���Vf�f�7�lOR9 ��1/i�� F'Ii�AL ; <br /> I���ALL�Ti�f� CFiE�K�.BST <br /> ; <br /> i <br /> Installation Company Name and Conlact Inio: ��-{, � I-!!��a��/ L LG � <br /> • ' i <br /> Date Bacinvater PreveNion device (8WD)�vas installed: _ Date this form�rras compieled: ' <br /> � <br /> .�nstallation Property Owner Name and Contact Info: Gary G. DeMellaWelis ; <br /> � <br /> Property Address: 1830 Oakes Avenue, Everett, N/A-98201 425/258-4330 <br /> Pre-Installation Inspection Checklist: ' <br /> All ilems rnusf be checked�Yes'in order!or a BV✓D fo be considered(or instaflalron <br /> Is Ihere a 6asement or level of the house that is at or near assumed setver main elevation?[] Yes ❑ No � <br /> Are there fxlures in the house located belov�ihe upstream seever manhole rim elevation?,�Yes ❑ No ; <br /> Is the side sewer currenlly UNPROTECTED from sevrer backups (does not have a 61ND instalied)? � Yes ❑ No , <br /> Site Inspection Checklist: <br /> All iiems rnust be ch�cked'Yes'bef�re inspecGon is considered complete 1' <br /> i <br /> Was side sewer N i�specled (rom building ro sewer main? �}Yes ❑ No Condition: i <br /> Does side sewer have at least 1°o slope frcm the building to sawer mainl �.Yes ❑ No Describe: � <br /> Have all building sewer drain connections to t��e side se�ver been idenlified and located? [�.Yes ❑ No <br /> Ha��e all property storm drainage connections lo the side sewer been identified and localed? [%�,Yes ❑ No � <br /> Has property been evaluated for drainage de5ciencies with findings communicated lo property o�vner? Q Yes ❑No ; <br /> Installation Details: <br /> What type and brand of B1ND was installed at this site(Clean Cherk BWV, Grinder pump,etc.): Cl�av� c�e�<<- <br /> Where was the device installed(general description, aflach map)? ���}�;� �c�v S-e. ? <br /> � <br /> � <br /> Was ihere any olher se�:�er or slorm drainage work completed in conjunclion with�1ie BWD work? Is so please descnbe:_ <br /> �v � <br /> Installation Checklist: � <br /> Are all downspouls and site drainage disconnected (rom upslream of the BWD? �1'es ❑ No Commeils: � <br /> Does BWD positioning meets minimum slape requirement of>1%? �Yes ❑ No Commenls: ! <br /> Can BWD be pulled out lor inspeclion and maintPnance afler loosening Ihumb scre�v? �.Yes ❑ No i <br /> Is DWD lucked inlo the proper position a �b,�mb screw lightened? .�.Yes ❑ No <br /> Circle Ihe BVJD cover: irrigation ccv r(I ndsc pe area I traffic load bearing cover(drive surface)1 access halch(building) � <br /> Was properly cwner shown ihe location f th ins�alled BWD? (�Yes ❑ No Commenis: i <br /> Properly O�vner's Signature: ca__�Y�eM1lellodVells Dale: 13-March-2015 I <br /> Inslailer's Signalure: �-R- � Date: "Z I�7��b � <br /> Revision: Z 1 FridaV, September 12, 2014 � <br />