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2013 LARGE STORM RESPONSE PAPER FORM CHECKLIST <br /> Date of inspection: Inspected By: l .pa r <br /> Address: 1;7 t/ frC Service Request Number: <br /> �a <br /> Resident: ° G e� "t.. Owner? it YES ❑ NO <br /> Phone Number: Email: <br /> General Building Details: <br /> Is this building within the combined sewer area?,01YES ❑NO Does the building have a basement?'YES ❑NO <br /> Does the building have a backwater valve(BWV)? ❑YESJ O (If yes)Was BWV installed through City program ❑YES ❑NO 44041 <br /> Does the building have a sump pump? ❑YES,1NO Does the building have a grinder pump? ❑YESO <br /> Storm Event Details: <br /> Where did water entering building come from? ❑SURFACE FLOW ❑GROUNDWATER !4t SEWER BACKUP-FIXTURES ❑UNKNOWN <br /> Details: <br /> Elva d`iin " S£ al <br /> Where did water go within the building? SEMENT PERIMETER ❑ BASEMENT NEAR FIXTURES ❑OTHER <br /> P <br /> Details: c< !` / ii+fo <br /> .", <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: 2-f v' ; 2 ''di Afi v I <br /> Previous"flooding"issue Service Requests at ad ss: ` ' c • <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: d`? k ad <br /> • 4' <br /> Revision: 3 TRW 1 Thursday, September 05, 2013 <br />