HomeMy WebLinkAboutwell info ' m MINNESOTA DEPARTMENT OF NEALTH
;� WELL DISCLOSURE CERTIFICATE
u � PLEASE TYPE OR PR/NT ALL INFORMATION
Person filing deed must attach$1D fee payab/e to county recorder.
A. PROPERTY DESCRIPTION
Attach a legal description of property if the property does not have a lot number, biock number,
and adtlition name.•
COUNTY LOT NUMBER BLOCK NUMBER ADDITION NAME
Hennepin 5 & 6 3 Saga Hills revised
STREET ADRESS
1295 Loma Linda Avenue
CITY STATE ZIP CODE
Orono MN 55364
B. PROPERTY BUYER MAILING ADDRESS AFTER CLOSING
FIRST NAME MIDDLE INITIAL LAST NAME
Ursula J. Platteter
COMPANY NAME (IF APPLICABLE)
ADDRESS " �
ADDRESS
1295 Loma Linda Avenue
CITY STATE ZIP CODE TELEPHONE NUMBER
Orono lyN 55364 � �
C. CERTIFICATION BY SELLER
I ce�tify that the information provided on this certificate is accurate and complete to the best of my knowledge.
J �__��� Y
Signature of Seller or Designated Representative of Seller Date
D. CERTIFICATION BY BUYER
The buyer or person authorized to act on behalf of the buyer,must sign a Well Disclosure Certi(icate(or all deeds given in tultiltment of
a contract tor deed if there is a well on the property.
In the absence of a seller's signature,the buyer,or person authorized to act on behali ot the buyer may sign this well certificate.
No signature is required by the buyer if the seller has signed above.
Based on disclosure iniorrpation provided to me by the seller or other available iniormation,I certity that the in(ormation on Ihis certificate
is accurate and complete to the best of my knowledge.
Signature of 8uyer or Designated Representative o(Buyer Date
(OVER)
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REALTOR
arlelnp out o!use or mieuse ot lhla torm
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�, Pl�ee� uee th� ep�ce below to �k�t�h the �aal propaly boinp aold and lha loc�tbn of each ❑SEW�cR SY�STEM� VVELL on th�prop�rty.
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ACH ADDITIONAL SH6ETS AS NEEDED
1. 9aAsr end Buyst Initinl: Sellor(e)�l' 8�y�f(e) ���`��I
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7. MN�PSSWM�1/94) 'ol�lolNAl COPY TO USTING 6RoK�RO COPIE6 TO SELLEfi,6�11Yl.'K�a�LL.TMa aRaKER
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