FILE WITH RECORDER DNR form 542-0960 (July 18, 2012)
5. Private Burial Site (check one)
There are no known private burial sites on this property.
There is a private burial site on this property. The location(s) of the site(s) and known
identifying information of the decedent(s) is stated below or on an attached separate sheet, as
necessary.
6. Private Sewage Disposal System (check one)
All buildings on this property are served by a public or semi-public sewage disposal system.
This transaction does not involve the transfer of any building which has or is required by law to
have a sewage disposal system.
There is a building served by private sewage disposal system on this property or a building
without any lawful sewage disposal system. A certified inspector’s report is attached which
documents the condition of the private sewage disposal system and whether any modifications
are required to conform to standards adopted by the Department of Natural Resources. A
certified inspection report must be accompanied by this form when recording.
There is a building served by private sewage disposal system on this property. Weather or
other temporary physical conditions prevent the certified inspection of the private sewage
disposal system from being conducted. The buyer has executed a binding acknowledgment
with the county board of health to conduct a certified inspection of the private sewage disposal
system at the earliest practicable time and to be responsible for any required modifications to
the private sewage disposal system as identified by the certified inspection. A copy of the
binding acknowledgment is attached to this form.
There is a building served by private sewage disposal system on this property. The buyer has
executed a binding acknowledgment with the county board of health to install a new private
sewage disposal system on this property within an agreed upon time period. A copy of the
binding acknowledgment is provided with this form.
There is a building served by private sewage disposal system on this property. The building to
which the sewage disposal system is connected will be demolished without being occupied. The
buyer has executed a binding acknowledgment with the county board of health to demolish the
building within an agreed upon time period. A copy of the binding acknowledgment is provided
with this form. [Exemption #9]
This property is exempt from the private sewage disposal inspection requirements pursuant to
the following exemption [Note: for exemption #9 use prior check box]: ____________________.
The private sewage disposal system has been installed within the past two years pursuant to
permit number ____________________________________________.
Information required by statements checked above should be provided here or on separate
sheets attached hereto:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I HEREBY DECLARE THAT I HAVE REVIEWED THE INSTRUCTIONS FOR THIS
FORM
AND THAT THE INFORMATION STATED ABOVE IS TRUE AND CORRECT.
Signature: _______________________________________ Telephone No.: (_____)_____________
(Transferor or Agent)
