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HomeMy WebLinkAboutwell info MINNESOTA DEPARTMENT OF HEALTH 'Wh Muni»mak Wjhk ®.fat®kb'b.fit.auk.MMM' A 41Z�M--44 air 1 J WELL DISCLOSURE CERTIFICATE K&ASE TYn OR PRii/,VT At L INFOR aATION Penon tiling deed most attach n $20 fee payable to the county recorder. A. PROPERTY DESCRIPTION Arach a leWl description of the property if the property does not ha" a lot number, block number, and addition name. CTv LOT NUMBERBLOCK-NUMBER ADOITION NAME iaj f l �u��e o 1 v3b CITE NATE ZIP CODE P.I.N.NO.(OPTIONAL) B_ PROPERTY BUYER MAILING ADDRESS AFTER CLOSING fiWir NAME MIDDLE INITIAL LAST E 5 -7 - CWPAVY XMIE(IF APPLICABLE) ABORESs CITY STATE ZIP CODE TELEPHONE NUMBER �i��a-z��� ✓'S�- SS 3� t C- CERTIFICATION BY SELLER `I 1 cer*that the information provided on this certificate is accurate and complete to the best of my knowledge. i •�� o ��.5�©01 Signature of Seller or Designated Representative of Seller Date D. CERTIFICATION BY BUYER r The buyer or person authorized to act on behalf of the buyer, must sign a Well Disclosure Certificate for all deeds given In fulfillment of a twb act for deed if there is a well on the property. In the absem of a seller's signature,the buyer,or person authorized to act on behalf of the buyer may sign this well certificate. No signature is required by the buyer if the seller has signed above. Based on disdosure information provided to me by the seller or other available information, I certify that the information on this certificate its accurate and complete to the best of my knowledge. V Signature of Guyer or Designated Representative of Buyer Date (OVER) r � MINNESOTA DEPARTMENT OF HEALTH . WELL DISCLOSURE CERTIFICATE PLEASE TYPE OR PRINT ALL INFORMATION *-Fill out a separatewell information page if more than three wells are located on the property. WELL #1 COUNTY QUARTER(OR GOVERNMENT LOT) I SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER )kAllki WELL STATUS (Check only one box) YEAR WELL WAS SEALED(i WN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) NAME OF LICENSED WELL CONTRACTOR If the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not In use. WELL #2 " COUNTY QUARTER(OR GOVERNMENT LOT) SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER WELL STATUS (Check only one box) YEAR WELL WAS SEALED(IF KNOWN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) _ NAME OF LICENSED WELL CONTRACTOR IIf the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not in use. WELL #3 COUNTY QUARTER(OR GOVERNMENT LOT) SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER WELL STATUS (Check only one box) YEAR WELL WAS SEALED(Ir KpOWN) WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑SEALED BY LICENSED WELL CONTRACTOR(3) NAME OF LICENSED WELL CONTRACTOR It the well has been sealed by someone other than a licensed well contractor or a licensed well sealing contractor,check the well status as not In use. SKETCH MAP—Sketch the location of theweli(s)and include estimated distances from roads,streets,and buildings. IF MORE THAN ONE WELL ON PROPERTY,USE THE WELL LOCATION NUMBER ABOVE TO IDENTIFY EACH WELL K�✓I d e ti/ft 1 w� LL f o LL) Information provided on this form is classified as pub0c Information under Minnesota Statutes,Chapter 13. To request this document In another format call(612)215-0700 or TDD (612)215-0707,or greater Minnesota through Minnesota Relay Service at 1-800-627-3529 and ask for(612)215-0811.