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� . ' ' COUNTY USE ONLY MDH USE ONLY <br /> MINNESOTA DEPARTMENT OF HEALTH <br /> Well Management Section,P.O.Box 64975,St.Paul,Minnesota 55164-0975 <br /> 651/201-4587 or 800/383-9808 <br /> WELL DISCLOSURE CERTIFICATE <br /> PLEASE TYPE OR PRINT ALL INFORMATION <br /> Person filing deed must include a$45 fee payable to the county recorder. <br /> A. PROPERTY LOCATION LEGAL DESCRIPTION <br /> Attach a legal description of the property. <br /> County ! Section No. Township No. Range No. I Quarter(or Govemment Lot) <br /> Henne in ' � <br /> Lot No(s). Block No. I Addition Name �, Outlot ,' Tract <br /> PropeRy Street Address <br /> 300 S Brow�Road <br /> City/Township i Zip Code I Property ID No./Parcel No.(optional) <br /> Orono i 55356 0311723130002 <br /> B. PROPERTY BUYER MAILING ADDRESS AFTER CLOSING <br /> First Name Middle Initial Last Name <br /> Richard N. Chalfen <br /> Company Name(if applicable) <br /> Mailing Address <br /> Mailing Address <br /> City 'I State/Province Zip Code � Telephone No.(including area code) <br /> Provide Name of Seller(please print) Jack C.Douthit and Hazel E.Douthit <br /> C. CERTIFICATION BY SELLER <br /> I certify that the information provided on this certificate is accurate and complete to the best of my knowledge. <br /> �G>�i �ii��r � 9�3 u / /� <br /> Signature of Seller or Designated Representative of Seller Date� � <br /> D. CERTIFICATION BY BUYER <br /> For fulfillment of a contract for deed,the buyer or person authorized to act on behalf of the buyer,must sign a Well Disclosure <br /> Certifcate if there is a well on the property. <br /> In the absence of a seller's signature, the buyer, or person authorized to act on behalf of the buyer may sign this Well <br /> Disclosure Certificate. No signature is required by the buyer if the seller has signed above. <br /> Based on disclosure information provided to me by the seller or other available information, I certify that the information on this <br /> certificate is accurate and complete to the best of my knowledge. <br /> Signature of Buyer or Designated Representative of Buyer Date <br /> IMPORTANT NOTE: The Minnesota Department of Health(MDH)wiil foliow-up with the property buyer regarding any wells <br /> disclosed as not in use. If a well is not in use,the property owner must either retum the well to use,have the well sealed by a <br /> licensed well contractor, or obtain an annual maintenance permit from the MDH for$175. A copy of this Well Disclosure <br /> Certificate should be provided to the property buyer at the time of closing. <br />