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4 <br /> i <br /> A <br /> l <br /> 2 <br /> BACKWATER PREVENTION DEVICE FINAL k <br /> INSTALLATION CHECKLIST <br /> fi <br /> Installation Company Name and Contact Info; CJ's PLUMBING&SERVICE LLC 360-691-5159 <br /> Date Backwater Prevention device(BWD)was installed: Date this form was completed: j <br /> Installation Property Owner Name and Contact Info: f <br /> Property Address; ..__. <br /> i <br /> Preinstallation Inspection Checklist: 1 <br /> All items must be checked'Yes'in ordRr fora 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 /> 4 <br /> Are there fixtures in the house located below the upstream sewer manhole rim elevation?0 Yes ❑No i <br /> Is the side sewer currently UNPROTECTED from sewer backups (does not have a BWD installed)?F]Yes El No <br /> Site Inspection Checklist: <br /> r <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: 1�L <br /> Does side sewer have at least 1%slope from the building to sewer main? [[]Yes ❑ No Describe: <br /> f <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? [Z]Yes ❑ No <br /> Has property been evaluated for drainage deficiencies with findings communicated to property owner? 0 Yes ❑No j <br /> Installation Details: f <br /> What type and brand of BWD was installed at this site(Clean Check BWV,Grinder pump,etc.): RX 0ea"0)"Iye— <br /> Where was the device installed (general description,attach map)? _a( j` py!;r <br /> Was there any other sewer or storm drainage work completed in conjunction with the BWD work?Is so please describe: <br /> i <br /> i <br /> 4 <br /> Installation Checklist: <br /> Are all downspouts and site drainage disconnected from upstream of the BWD? KI Yes ❑ No Comments: <br /> Does BWD positioning meets minimum slope requirement of>1%? (FYes ❑No Comments: <br /> Can BWD be pulled out for inspection and maintenance after loosening thumb screw? M Yes []No <br /> Is BWD locked into the proper position and thumbscrew tightened? [4jYes ❑ No <br /> Circle the BWD cover Irrigation ver(landscape area)1 traffic load bearing cover(drive surface)1 access hatch(building) <br /> Was property owner shown installed BWD? MYes ❑No Comments: <br /> Property Owner's Slgnat Date: <br /> Installer's Signature: Date: ��` .2c/— <br /> Revision: <br /> 2cRevision:2 1 Friday,September 12,2014 <br />