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2013 LARGE STORM RESPONSE PAPER FORM CHECKLIST <br /> � <br /> : l,� n <br /> – - Da;eofinspection:---y��b/�.j---- --InspecteABy: ��{�( � /"(/� �!. __ �-- <br /> Address: I S I S l7dLl r ( �y/7 �/R��.d/R 1� Service Request Num�r. . <br /> Residenl: �/i L—��f��(��'�`� ,J Owner7 ❑YeS ❑MO <br /> Phone Numbcr, Email: <br /> General Building Details: <br /> Is Ihis 6uilding velhin Ihe combinetl sewzr area? �YES �NO Does ihe building have a oasemenl7 If�YES ❑NO <br /> Does the huilding have a 6ackwa�er valve(BW1�? ❑YES�NO Q(yes)Was BWV i.�stal�ed through Gty program ❑YES �NO <br /> Dces ihe 6uilding have a sump pump? ❑YES �NO Does the nuiiding have a gnnd=_r pump? �YES,$IND <br /> Storm Event Details: <br /> lSmere di�v.aler enlenn�building comc Irom? �SURFAGE FLOVJ ❑GROUNDWFTFR�SEWER BFCKUP-FIXTURES �UNKNOWN <br /> Details: ��o�r v?�^�" <br /> lMieredidwalergovtlthinNe6uilding? �],BASEtdENTPERIMETER OBASEMENTNEARfIXTURES ❑OTHER <br /> o:ca��s lUa//- �- Lt�a// /`�6/a �' d��n ��!-cr e%,- ✓n ce) <br /> Site Observations: <br /> Downspoul 1 site grading issues noted: I L�[Rt rl Fg9'�� _ <br /> 6wlding etevafion relative lo sewer and surtounding area issues noled: _ <br /> Sile pump issues noted:______� <br /> Historiwl Informatlon I Olher Informatlan: <br /> Previous'Iboding'issuz Serrice Requests al address�. <br /> Previous'llaoding'issues noled by homeo�mcr. c�V�� __ <br /> Recent stormwater I sewer pm�eds completed in ama: Proposed slormwater!sewer projecls m area� <br /> Piopeiry oNner iNerested in heginning Cih�Barkwater Valv.?mg2m at adAress:�.Y[S 0 NO Cetails: <br /> haies: ,�e�4n+�rrxln,�ei� a�6w�,s.Oclr��''':•�nn�.�Pe� �„rt��n ir� .FA ��c�.�o� <br /> ��—����'' I d <br /> Rcei.inn: i TRW 1 Thursday,Septem6er O5, 201 3 <br />