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2013 LARGE STORM RESPONSE PAPER FORM CHECKLIST <br /> Daleofinspeclion��/ �/IJ _ InspectedBy'�(//�„� I�Ga��n��/ •�(J���._ ! l-�� <br /> Address:� �r� �`! v�' Service Reques!Number: <br /> ResidenC Q ��"/I� � ✓����f G MI��i�l� Ov.�ner? � YES �NO ((�(��j _ <br /> Phone Numbec Email. <br /> General Building Details: <br /> Is Ihis huilding wiNin Ihe combined sewer area? YES �NO Dces Ihe buildinc�have a basemenl? �YES �NO � S Ty�`� � <br /> �oes the building have a backwater valve(BNN)7 ❑YES NO (II yes)Was BNN inslalled Ihrough Gty progmm �Y S [�}'No�'3�VV k <br /> '� ,v�(/.,�e. <br /> Dces Ihe building have a sump pamp? �YES t 7 NO Does the building have a grinder pump? ❑YES - NO <br /> Storm Event DeWils: <br /> N`here did waler entenng bui!ding wme Bom? ❑SURFACE FLON' ❑GROUNDWATER [�SEWER BACKUP•FIXTURES ❑UNKNOWN <br /> ; Delails: �ll�J/ //�n � TU(i P� <br /> lNhere did water go vrithin Ihe building7 ��SEL�ENT PERI�dETER ASEMENT NEAR FIXTURES �OTHER � <br /> ! Delails��5 ��+IUuM i �"7��, r�U M _ � <br /> ��� Site 06servatians: <br /> � Dor+nspout l sile grading issues noted:�hd �lfPo� - <br /> �uilding eievalron relalive lo sewcr and surrounding area issues noted: I��i J (`�������/"+ S rlJ�-'�'�-1 r�� �`��1 <br /> � / <br /> Sile pump issues noled:� _ <br /> Historical Information I Olhar Information: <br /> Previous'Oauding'Issue Service Requests at address _ <br /> i, / '/^ <br /> Previous'llooding'issues iwled by homw�vncr.,LN 1 �P��+— ��J((4�, N� l��'l�b�n�ti �^- !�s <br /> Recen�stoimwaler 1 sewer projecls compieted In area: Proposed slorm�vater 1 sewer p�ojecls in area: <br /> Properly owner interesled in beginning City Backwater Valve Program al address: YES []NO Details: <br /> Noles:,�'�C✓S �fpM+L 0nt � f(�� � �/'1'Ti�L�(�(3�V <br /> t�r, r '/�� f� 1u�Uz /�:z ,'�s�rr.��;� . <br /> Revision:3 TRW 1 Ttiursday,September O5,2013 <br />