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Well Management Unit,925 Delaware a$trod S��eOTA DEP904 RTMppooIN MI Or n5E45A9-4D ( 12)627.5408 or 1.800-383.9808
' WELL DISCLOSURE CERTIFICATE
PLEASE TYPE OR PRINT ALL INFORMATION
Person filing deed must attach a $20 fee payable to the county recorder. 1 8 B 9 5 1
A. PROPERTY DESCRIPTION Q
Attach a legal description.ofthe property if the.property does not have-a lot number, block.number, .
and addition name.
COUNTY LOT NUMBER BLOCK NUMBER ADDITION NAME
Washington 1,2,3,4 4 Cloverdale
STREET ADDRESS
3585 Laverne Avenue
CITY STATE ZIP CODE
Lake Elmo M 55042
B. PROPERTY BUYER MAILING ADDRESS AFTER CLOSING
FIRST NAME MIDDLE INITIAL LAST NAME
Charles H Siedow
COMPANY NAME(IF APPLICABLE)
ADDRESS
ADDRESS
3585 Laverne Avenue
CITY STATE ZIP CODE __fTELEPHONE NUMBER
Lake Elmo M 55042 ( 612
C. CERTIFICATION BY SELLER
I certify that the information provided on this certificate is accurate and complete to the best of my knowledge.
Signature of Seiler 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 Certificate for all deeds given in fulfillment of a
contract for 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 behalf of the buyer may sign this well certificate.
No signature is required by the buyer if the seller has signed above.
Based on disclosure information provided to me by the seller or other available information, I certify that the information on this certificate
is accurate and comp) e t the b st of my nowledge.
Signature of Buyer or 06signated Representative of Buyer Date
(OVER)
MINNESOTA DEPARTMENT OF HEALTH
t WELL DISCLOSURE CERTIFICATE
PLEASE TYPE OR PRINT ALL INFORMATION
*fill out a separate well information page if more than# wells are located on the property..
WELL#1
COUNTY QUARTER NW 1/4 SECTION NUMBER TOWNSHIP NUMBER RANGE NUMBER
Washington 13 29 21 W
WELL STATUS YEAR WELL WAS SEALED(IF KNOWN)
WELL IS: ® IN USE(1) ❑ NOT IN USE(2) ❑ SEALED BY LICENSED WELL CONTRACTOR(3)
WELL #2
COUNTY QUARTER SECTION NUMBER TOWNSHIP NUMBER I RANGE NUMBER
WELL STATUS YEAR WELL WAS SEALED(IF KNOWN)
WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑ SEALED BY LICENSED WELL CONTRACTOR(3)
WELL #3
COUNTY QUARTER SECTION NUMBER TOWNSHIP NUMBER I RANGE NUMBER
WELL STATUS YEAR WELL WAS SEALED(IF KNOWN)
WELL IS: ❑ IN USE(1) ❑ NOT IN USE(2) ❑ SEALED BY LICENSED WELL CONTRACTOR(3)
SKETCH MAP—Sketc thelxationofthewell(s)andinclude"dinateddistancesfrom roads,streets,and buildings.
IF MORE THAN NE ELL ON PROPERTY,USE THE WELL LOCATION NUMBER A13OVE TO IDENTIFY EACH WELL.
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Information provided on this form is classified as public information under Minnesota Statutes, Chapter 13.
To request this document in another format call 627-5100 or TDD through Minnesota Relay Service at(612)297-5353 or toll free
1-800-627-3529 (Greater Minnesota).
HE-0 t 387-03 11/93R