Sewer Complaint Form

1

Date:

 *

Date:

2

Alleged Violators Name:

Alleged Violators Name:

3

Alleged Violators Phone #:

Alleged Violators Phone #: ext.

4

Location of Alleged Violation:

Location of Alleged Violation:

Lot #

Blk.

Sec.

5

Is the Alleged Violation located inside the City limits?

Is the Alleged Violation located inside the City limits?

Yes

No

6

Subdivision:

Subdivision:

7

Acreage:

Acreage:

8

Violator's Mailing Address:

 *

Violator's Mailing Address:

Street

City:

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

9

County:

 *

County:

10

JP Precinct:

 *

JP Precinct: (Select an Answer) JP 1 - Athens JP 2 - Seven Points JP 3 - Chandler JP 4 - Poynor JP 5 - Malakoff

11

Residence:

 *

Residence:(Select an Answer) Permanent Weekend Rental Business Unknown

12

Name of Person Submitting Complaint:

 *

Name of Person Submitting Complaint:

13

Complainant Phone #:

 *

Complainant Phone #: ext.

14

Nature of Complaint:

 *

Nature of Complaint:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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