Nuisance Investigation Report

This complaint will be submitted to Wayne County Health Department located in Wayne, WV.

I request an investigation of the public health hazard or nuisance described below:

Location (be specific):

Person or Persons Responsible for the Condition

Name:

Address:

Phone Number:

Owner of Property (If different from Person or Persons Responsible)

Name:

Address:

Phone Number:

Person Requesting the Investigation

Name:

Address:

Phone Number:

Email:

Complaint details

How long has this condition existed?:

Have you reported this condition to the person reponsible? Yes No

Was this condition reported to the health department previously? Yes No

When?:

To another agency? Yes No

Which?:

By making this request for an investigation, I acknowledge that the health department may take all necessary steps consistent with the appropriate laws to investigate and effect correction if such is warranted. Such action may involve referral to other agencies or legal action that may require the need for court appearance and testimony to corroborate the conditions stated in this complaint. I also realize that information submitted over the internet may not be secure.

Acknowledge? Yes No

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Nuisance Investigation Report

Person or Persons Responsible for the Condition

Owner of Property (If different from Person or Persons Responsible)

Person Requesting the Investigation

Complaint details