S:\0. ADMIN\2. Forms\Form 10. Complaint Form\L&RM Form 10_Complaint Form.docx

L&RM FORM 10 INCOMPLETE FORMS WILL BE RETURNED Pope County Land & Resource Management 130 East Minnesota Ave. Suite 113 | Glenwood, Minnesota 56334 |

Phone: (320) 634-7791 | Email: pub.lrm@co.pope.mn.us Page 1 of 2 Website: https://www.co.pope.mn.us/departments/LandResourcesManagement

COMPLAINT FORM

This form is used to record complaints. The complaint form must be signed and dated by the organizational Principal/Director or owner before submission to Pope County.

Location of Alleged Nuisance Today’s Date Lake or River Name

Property Address City State Zip

Township Name Section Twp Range

Parcel No. - - Associated Parcel No. - -

Property Owner Information Property Owner Name

Phone Number Email

Mailing Address City State Zip

Complaint Nature of Complaint

Prior Complaints in the Past

Complainant Information Complainant Name Phone Number

Email

Anonymous Complainant

Complaint Received by L&RM Staff Name Signature Date

S:\0. ADMIN\2. Forms\Form 10. Complaint Form\L&RM Form 10_Complaint Form.docx

L&RM FORM 10 INCOMPLETE FORMS WILL BE RETURNED Pope County Land & Resource Management 130 East Minnesota Ave. Suite 113 | Glenwood, Minnesota 56334 |

Phone: (320) 634-7791 | Email: pub.lrm@co.pope.mn.us Page 2 of 2 Website: https://www.co.pope.mn.us/departments/LandResourcesManagement

L&RM OFFICE USE ONLY

Investigation of Alleged Complaint Situation

Owner Notification

Property Owner Notified by:

Property Owner Witnessed Investigation

Other Parties Witnessed the investigation (indicate names & phone numbers)

Evidence

Pictures Taken (indicate number taken)

Water Sample Taken (indicate location of sample)

Elevation Reading (indicate location of reading)

Dye Test Applied and Dye Seepage Appeared in: Lake / River / Stream / None

Other Measurements, Readings or Tests Taken (describe in space provided)

Investigator Recommendation

Disregard Complaint – No Action Necessary (indicate reason)

Action to be taken (indicate remedy)

L&RM Investigator Certification

Form Complete

Follow-Up Investigation to be Made on

Investigator’s Name Signature Date

COMPLAINT FORMLocation of Alleged NuisanceProperty Owner InformationComplaintComplainant InformationComplaint Received by L&RM

L&RM OFFICE USE ONLYInvestigation of Alleged ComplaintOwner NotificationEvidenceInvestigator RecommendationL&RM Investigator Certification

Todays Date: Date: Lake or River Name: Township: [ ]Section: [ ]Township#: [ ]Range: [ ]Property Owner Name: Nature of ComplaintRow1: Prior Complaints in the PastRow1: Phone Number_2: Complainant NameRow1: Email_2: Staff Name: Property Address: 2Parcel No7-9: City_2: State_2: Zip_2: Parcel No1-2: Parcel No 3-6: Parcel No 7-9: 2Parcel No1-2: 2Parcel No 3-6: Phone Number: Email: Mailing Address: Zip: City: State: Name: Check Box1: OffSituationRow1: Date_2: Property Owner Notified by: Property Owner Witnessed Investigation: Other Parties Witnessed the investigation indicate names phone numbers: Pictures Taken indicate number taken: Water Sample Taken indicate location of sample: Elevation Reading indicate location of reading: Lake River Stream NoneOther Measurements Readings or Tests Taken describe in space provided: Disregard Complaint No Action Necessary indicate reason: Action to be taken indicate remedy: Investigators Name: Check Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: Off