State of West Virginia: Wayne County Health Department Nuisance Investigation Report

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

        Location (Be Specific):

        Person of Persons Responsible for the Condition

        Name:       

        Address:   

        Phone Number:   

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

        Name:       

        Address:   

        Phone Number:   

        How Long Has This Condition Existed?   

        Have You Reported This Condition To The Person Responsible?    Yes    No

        Was This Condition Reported To The Health Department Previously?    Yes    No

        When?   

        To Another Agency?    Yes    No

        What Agency?

        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.

        Person Requesting the Investigation:

        Address:   

        Phone Number:   

        Date:   

     Your email address: