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I COM Number:
Confidential:
Jefferson County Department of Community Development Citizen Concern/Complaint Form
Date of Report ~ - \ ' a ~
Information Taken By (staff name)
Confidential...J Yes ...J No
Notify of Response ...J Yes ...J No
Citizen Filing Concern/Complaint (if requested to be confidential, please write "CONFIDENTIAL" here in red.)
Full Name ..J tl C"., .b {~ (' r. ' Phone 3b't?- '5 05'- 5: Z "2 (
Street or Mailing Address p~~ 1 ~O, t:t)X/1acu/f7) fA/A crc'3' 22'
1/",-
Concern/Complaint Regarding (must get this information!) , ell A5'E GCJ} P Co (/('~:J
, Full Name ~ a' e L 1- C- 011 fV Phone
56.:? :2
Parcel number
Location of Problem
Problem or Adjacent Address (;~J/L/>r o,~ D f5';;(l \Ie r v !<<?q)
/
Are there any gates, dogs, no trespassing signs, mile markers, etc?
12A/JCADP G&o~~ RoaJD,
~f FJL/R GrIVEf') rC'JaJ
Program Area: ...J Abandoned Vehicles
r< oln U
e t Ef_ do 0' wa,,A/f/Y y acre~e-.ArC"C<
...JDCD (specific division, if possible) ...JNuisance 0 Other (/('hdNI2-eJ ' If-
/5 6-be1(-~val f1tthe Je tku~~ ~VAJ~
Date: ( CL/ vepa~{j-p ~ j(5e! ~ l'
t:1;v,J. My Netjh be) ()/
...J Yes ...JNo -If "Yes", forward a copy of this tbrm to County
Assigned To DCD Staff Name:
Is there a "no access" letter or notice on file with the County?
Administrator -
Any site visitation due to this complaint will be in comoliance with Jefferson County policies and procedures regardinl!: trespassing.
No action necessary because: ...J no potential violation in complaint...J complaint has already been investigated on
...J referred to ...J other
Conditions Found and Actions Taken
~
AU6 0 1 2006
JEf~h~UN &OUNlYllCD
Admin Time Spent:
Date Completed:
DCD Time Spent: Director Time Spent: CCC Time Spent:
Person Complained Notified: ...J Yes ...J No Parcel Number:
lOG ITEM
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Page__ '. _.Of._2-
Referred to inspector for investigation. Assigned Date
Date Action
Additional Comments or directions to property:
Action Summary: .
Site Visits: 0 1 2 3 4 5 6 7 8 9
o Informational Letter Sent: ~~ _ 0 Prosecuting Attorney's letter sent ~ ~ ~
o Notice and Order Sent: / /
o Ticket #
Written ~~_
Abated? Y N
By
~~-
CAncelled FOrwarded NoProblems REsolved UNresolvl'bG ITEM
# ' If~
Page~ L of z-
Please attach an activity report for field notes relevant ------
to this case. Please track all your time spent on each complaint!
2