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2013 LARGE STORM RESPONSE PAPER FORM CHECKLIST <br /> 477- <br /> Date of inspection: t(( 6'( /4 Inspected By: 13(7 .41 D©o/44 (r. <br /> derphhe_') <br /> Address: 1 2 2�-(r' 7 Q'f-- < Service Request Number: <br /> Resident: 01-1 V-4-1 Owner? ❑'S'ES ❑NO <br /> Phone Number: J b O 3 l"1 S-9-0 7/2-0 g162 is 4r• Email: <br /> #(4111 104M <br /> General Building Details: v; /0!1-? S • <br /> k <br /> Is this building within the combined sewer area? LEI YES ElNO Does the building have a basement? YES ❑NO <br /> Does the building have a backwater valve(BWV)? ❑YES �0 (If yes)Was BWV installed through City program ❑YES ❑NO <br /> Does the building have a sump pump? ❑YES ❑NO Does the building have a grinder pump? ❑YES ❑ NO <br /> Storm t Details: /'4_ <br /> Wh e did ter entering building come from? ❑SURFACE FLOW ❑GROUNDWATER ❑SEWER BACKUP-FIXTURES ❑UNKNOWN <br /> Details: <br /> Where did water go within the building? ❑ BASEMENT PERIMETER ❑BASEMENT NEAR FIXTURES ❑OTHER <br /> Details: <br /> Site Observations: <br /> Downspout/site grading issues noted: <br /> Building elevation relative to sewer and surrounding area issues noted: <br /> Site pump issues noted: <br /> Historical Information I Other Information: <br /> Previous"flooding"issue Service Requests at address: <br /> Previous"flooding"issues noted by homeowner: <br /> Recent stormwater/sewer projects completed in area: Proposed stormwater/sewer projects in area: <br /> Property owner interested in beginning City Backwater Valve Program at address:❑YES ❑NO Details: <br /> Notes: <br /> Revision:3 TRW 1 Thursday,September 05, 2013 <br />