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2. DRAINAGE COMPLAINT INVESTIGATION FORM
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Home Phone No.*
16. Work Phone No.
17. Fax No.
19. Date*
    Date
23. How large is the area affected by flood damage?*
25. If possible, attach a sketch showing names, address
26. If possible, attach a sketch showing names, address
27. If possible, attach a sketch showing names, address
31. Location of Flooding
    Show number of properties for all that apply
33. Village Property - Sidewalks
34. Village Property - Buildings
35. Village Property - Right-of-Ways
37. Village Property - Streets
    
    
38. Village Property - Other Facilities
    
    
39. Village Property - Other Governmental Property
41. Private Property - Buildings
    
    
42. Private Property - Yards
    
    
43. Private Property - Other (explain below)
45. Briefly describe area(s) of flooding:
49. Type of Flooding
    Show number of properties for all that apply
51. Overland flow from other parcels
    
    
52. Creek, pond or other body of water overtops its banks
53. Existing ditch of storm sewer surcharges
55. Existing combined / sanitary sewer discharges
56. Water collects at low spot with no outlet
57. Sump discharge results in constant running water
59. Other (explain)
60. Explanation:
64. Type of Flood Damages
    Show number of properties for all that apply
66. Structural damage to publicly owned facilities
67. Non-structural damage to publicly owned facilities
68. Structural damage to privately owned buildings
70. Non-structural damage to privately owned buildings
71. Damage to lawns, gardens, sheds, etc.
72. Other damage (describe below)
    
    
74. Briefly describe flood damages:
78. Health and Safety Hazards
    Show number of properties for all that apply
80. Street / Road impassable
81. Flooded basement
82. Sewage surcharging
84. Icing in winter
85. Ground saturated
86. Deep ponding in low area
88. Flooded garages
89. Flooded septic fields
90. Stagnant water
92. Other (describe)
93. Briefly describe unsafe or undesirable conditions:
97. Type of Assistance Requested*

    1. Request general advice on how to alleviate problem
    2. Request detailed engineering only
    3. Request 50% Village funding for project (standard amount) or
    4. Request more than 50% funding for project

    Check all that apply
99. If you selected "Request more than 50% funding for project", explain the reason for additional funding request:
103. List other residents interested in this specific project
105. First Name
106. Last Name
108. Address1
110. Address2
112. City
113. State
114. Zip
118. First Name
119. Last Name
121. Address1
123. Address2
125. City
126. State
127. Zip
131. First Name
132. Last Name
134. Address1
136. Address2
138. City
139. State
140. Zip
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142. 1. Receive an email copy of this form.
143. Email address

     This field is not part of the form submission.

144. Submit

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