HomeMy WebLinkAbout020-1347-50-000 ST. CROIX COUNTY ZONING DEPARI'''�
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AS BUILT SANITARY REPORT,
RECEIVED
Owner N 111411 ,
Property Address � � -3 " .,� ,�'r '/ f/ C? � ��
'�
City /State C,t/
Legal Description: '
Lot a S Block -- Subdivision/CSM # H O 41 To/�'.D �
i
1 14!: c w t /4, Sec. I T L'i N -R 1 q W, Town of k y..]�kSC N PIT4 - #• 0 z a / 3
SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION
t
Tank manufacturer I 5 rz SizePC Setback from: House 7 Well `t�b PAL 3
Pump manufacturer -r- Model ----
Alarm location -r- 7
(HOLDING TANKS ONLY)
Setbacks: Service road ' Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: LPA` Iq Width 3 Length Number of Trenches -
Setback from: House 4 - 7 Well I I 0Z P/I., �_ Vent to fresh air intake 1 2-4
ELEVATIONS
Description of benchmark I p l P E Cz-, s ic L�?� C�D��ILt� (�O ' (d Elevation
Description of alternate benchmark -SILL- D N ' L K� t. �"1 1 C C7 & f 14 i� Elevation 11q, Z
11 ► `j ?& r
Building Sewer Z' `V " T Inlet `"� f 2. 11
ST Outlet `�S= '� PC Inlet
t
_ kk1
PC Bottom """ Header/Manifold 7� 30 - d0 `Top of ST/PC Manhole Cover . r /
J /v� i r) ,
1 !o N
Distribution Lines ( ) '7.3 0 = Id 7.3 O = I Oq S O 7 30 I U 1 , $ ; -- � � ,i•s�oc
Bottom of System ( ) S it S= 10 7,75 ( ) 9, Si X04 � S ( ) /d� BS = I d S ms s' .
Final Grade It I' �5,- , O S ,19 - : 110, 7 � (� ) (P-15 E 101,75
Date of installation /g Permit number 33,9 t S' State plan number
Plumber's signature License number Z .S0 3 0 Date #v/ d //
Inspector
Complete plot plan w
I
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable. -
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INDICATE NORTH ARROW
Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: iX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 3 ,388-54
Permit Holder's Name: ❑ City ❑ Village M Town of: State Plan ID No.:
MILLER, SAM HUDSON
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
0 6 1 ( O(� Y P7 r / 020- 1347 - 50-000
TANK INFORMATION 1A _ S, 411 ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic SQ Benchmark 7• 1OQ
Aeration Bldg. Sewer 5 , yZ
Holding Ht Inlet d S ((Z Z5 —
TANK SETBACK INFORMATION t Ht Outlet v
TANK TO P/ L WELL BLDG. Air I to ntake ROAD et
Air
Septic f ,� L NA D
/
Header /Man. 2 a . '"
z / a
Aeratio NA Dist. Pipe �T:
olding Bot. System / %
2 s
PUMP/ SIPHON INFORMATION Final Grade 1� •� it z.
v o 3
acturer Demand 5 u e X01 b
Model Numbe PM
TDH Li Lrictio System TDH Ft
oss Forcemain Length Dia.
H ist.Towen
SOIL ABSORPTION SYSTEM
BED / WNCA ) Width r iqu
Len th r No. Of Tr PIT No. Of Pits Inside Dia. Lid Depth
DIME s Trenches PIT
I N
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LE G Manu gr r
INFORMATION TypeO , A AM er:
MA el,
System: G y , 4 NIT
DISTRIBUTION SYSTEM 12 s
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length � , Dia. A Spacing - - / 1114 >/00 `
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (include code discrepancies, persons present, etc.)
// LOCA TIQN , , HUDSON 11 29,19,1868, SE, SW 735 / p 'A CKER DR — M S`I`EAD LOT 25
( (We(/ � "." / l•it^� ) �, -� QfTTe /.J 1 ;,
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Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ly
SBD -6710 (R.3/97) D e pector'sSignat Cert No.
L
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
P 0 Box 7302
In accord with ILHR $3.05, Wis. Adm. Code
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Number
4
Personal information you provide may be used for secondary purposes E] Check if revision to previousa plibation
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
-So# KA At LL.- f 2 1, 114 S 14 ) 1/4, S T , N, R/9 E(
Property Owner's Mailing Address Lot Number Block Number
City State Zip Code Phone Number Subdivision Name or CSM Number
Up
/ (38'027 &9 Ho F 5
II. T YPE B IL IN (check one) ❑ State Owned o It Nearest Road
ci Public or 2 Family Dwelling - No. of bedrooms Tow OF O (CFfL AIL ( VF-
III BUILDING USE: (If building type is public, check all that apply) Pa cel Tax Number(s) W. 2q • M • 11
1 ❑ Apartment/ Condo eIl Zd v ' 3 Y7 — :� o —
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) -
A) 1. �( New 2 F] Replacement 3 C] Replacementof 4; ❑ Reconnection of 5_ E] Repair of an
____System ________ System _____________ Tank Only______________ Existing System . ......... Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
1 Seepage Trench L�AGN T 22 C] In-Ground Pressure 1 0 42 ❑ Pit Privy
13 ❑ Seepage Pit / N r i„TR A Ina /L 3 " 3 A 7 S 43 ❑ Vault Privy
14 ❑ System -In -Fill I lye 396 V
VI. ABSORPTION SYSTEM INFORMATION. y
d �* 2 T
1. Gallons Per Day 2. Absorp. Area 3. Abs p reaoading Rate 5. Perc. Rate 6. S � ystem E ev. 7. Final Grade
40 Required (sq. ft.) Pr posed (sq. ft. (Gals/day /sq. ft.) (Min. /inch) 6 L G Elevation /,
Op �""" OMt Feet Mt.r Feet
Capacity
VII. TANK in Ca allo
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
e tic Tank , Sp 1:1 1:1 ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1131 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb er`s Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
MILE = ELL,_, r Z ZSO 3 Gr 71 r G V 4 ?
lumber's Address (Street, City, State, Zip Code):
1407 V t �
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing t Signature (No Stamps)
pp ❑Owner Given Initial
d roved Adverse Determination oo 100 Surcharge Fee)
_[
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
i
1 _ A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years_
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and;accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or-siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
I
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
I
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
a nd establishment of standards.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 0
Division of Safety and Buildings in ac=d wfth Comm 83.05, Wis. Adm. Code 'Eavi; By DU;;;16u
Attach complete site plan on paper not less than 8% x I I inches in size. Plan must County
include, but not limited to: vertic and horizontal reference point (SM), direction and St, Croix
Parcel I.D.#
7 11 :
Personal information you provide me 'L*'-for serd�Wurposes (Privacy Low, a. 15.04 (1) (m)). oy
ProDertv Owner
P party Location
Property Ownees Mailing Addrep� 1 Block # 1 Subd. Name or CSM#
city sul. PfioneN 71 City 17 Vfliaqe ZTown Nearest Road
WW urrib@r"
Hudson Hudson LABARGE
Replacement E P i or commercial describe
El P
Code Derived dafly flow It V gpo Recommended design loaaing rate d, gpdflt--±-�� trench, gpdff
Absorption area required, bed, fey(j trench, ft- maximum des. loading rate i bed, gpdff s 4P trench, gpff
tgn
Recommended infiltration surface elevation(s) c,5 eer Ae);ti'%qr A b ft (as referred to site plan benchmar
Additional design / site considerations
Parent material L, Q e-� p er (A ok I Ld a s Flood plain elevabon, if applicable —Z(2,A— ft
Depth inant Color Modes I Structure GPD
elev
-
|
limiting
factor 6
Depth to 5
thiting
ST Name (Please Print) Signature: Telephone No.
Thomas C. Nelson 715-246-2454
Address Envir0n=ntal BY Design Date CST Number Ref #
1432 12ft S#W, New Rictiniond, W1 54017 -8/19/98 227397 54
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• PROPERTY OWNER MILLER, SAM SOIL DESCRIPTION REPORT F 7 Page 2 of
PARCEL IDA En1virotRe I
Depth Dominant Color ( Mottles j j Structure j j GPDIf!'
Horizon in. Munsell I Pp. Sz. Cont, Color I Texture G r. Sz Sh onsistence Boundary I Roots
i i Bed Trench
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Remarks:
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Grouna ��� 7 S �� — �j M S 6 K �V'h V Fr C �J
E�r
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Depth to 5 /�, . R S 2 l< S
factor' , 6�
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Remarks: o
5 6 i 1 0 '' 10 y '2/1 j) td r I CW 1 2 IS
1 2& .301 10 F 3
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Depth to s
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factor 6
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Remarks:
Ground
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I I I I I
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Remarks:
ENVIgO BY DE51GN
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1432 120 STREET NEW RICHMOND, WISCONSIN
715- 246 -2454
PROJECT NAME HOMESTEAD PAGE 3
DESCRUMON SE Y SW 4, SEAT ON 11 T 29 N. R 19 W
TOWNSHIP Hudson COUNTY St. Croix Wisconsin
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SCALE I" = (40 Tom Nelson
BM 1. Lo CvvLv. e '' 0 J � v� ,r um 227387
BM 2. �� �� � l 6 o�►
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer M ILLER—
Mailing Address C ' s° )
Property Address - 72--T' -?A A'iFIL- D IZ t YE
(Verification required from Planning Department for new construction) 7
City /State pe"psd )y / Parcel Identification Number 4 ZO - / 3;z 7- So °C ► C&
LEGAL DESCRIPTION
Property Location Ste_ '/4, S W '/4, Sec. 1 , T �•9 N -R / 5)Town of Ho 0 5 op'l
'Subdivision HOAAE Lot # .
Certified Survey Map # S2'?) / 3 , Volume 7 Page # 3�
Warranty Deed # -31 , Volume Page #
Spec houseXyes 0 no Lot lines identifiable yes C3 no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
— 06NATUkk 00 k0OLICANT DATE
: OWNER CERTIFICATION
-4 1 {we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the prop it .described above, by virtue of a warranty deed recorded in Register of Deeds Office.
y //° / CD
'S10NATOICE 01? XPPtICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application; a stamped warranty deed from the Register of Deeds office
.a copy of the certified survey map if reference is made in the warranty deed
r -
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(� WA + DE? 11
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This Deed. ,ad, t•+ tHten on.i t i l I ie and
Sao, - )i R. Lillie, husband and fe
lid �am L. .`Miller, a sin5le pe>;son
•
Gr ,ntrc,
��'itnesseth Th:.t the :.t:d Iirantur, for a valuably cunslder.t.ur
.•o Cv, < t., t;rentre thr � d.•y•'rlLed real estate in
St Croix Ra.Lea CJ
l' ,ul.ty • State of K 'isct.IISIII
See attached description.
y TRAhUSFEH
This i [1Q t homvst,.A property.
(IN) (13 lint)
To,;+ -ti.er wah all and sing.dar the htredltaments unit appurtcn..nces trrunto t- aging:
Ai,d Ronald L. Willie and N R. hillie
u'rult; tt.rt the tidy Is ttu, „l, u:,lett.. ir. in ,unnitt and irtr ,,L,: cn.umhr:•.LC; csrcpt
ease; ents, r2stcictions, and ri hts -of -gray of rz. -
.nd w ll ,trtri.,nt and deiend t: L• >mue .
iratcd till, '� d.Cy t `larch
r� 9
(SEAL) � cruet L t l' c � t tL taEA1.)
• Ronald L. Willie
(S .A L1 /' . ".yc" 1-0 sr ,` /.. <GGC f. ISEAL)
. Naomi R. Willie
AUTHENTIC 1r10N ACKNOWLEDGMENT
STATE OF t•, I
59.
.... — . .. ..... ....... . ._ t. Croix ...- .. County'. n
authcntir::;td ti,i- day of 19._ Person:.. came bef-e me this . -1 ” .....day of
............._ .�! �CC,h -, ly 9u.. the :above n.amtd
._... .
__...Ronald..l... �tii.11ie. and.... __ ...... .
._...._ ..
TITLE: NIENIRER STATE Ii -t It C�F WISCuValti _ .-
t If nut.
author;:ed by ; 'IIkU';, st:,t:.y
to me known u, i,e the pt'r -.m .S. __ K't.0 executed the
furcgoing instr .mrnt and..ytk the same.
THIS "ITHUr.+LNf WAS C! ! eJ vy '•.\
C. L. Gaylord, attorney
I C T e 4
River Falls, l: 1 54022 _. x "t:• v P..I•.f $ .. _� � � ✓ county-, Wis.
I n. •I. t . r .v b, a al:ir,t,.I Lr ., ,.;r tti•. i, t l 16 a. �I ('nnit:u - Sl. r. n+p1krwithent. (If ndt. .Lac t<pir:ttion
11.41tkA DE1.0 ter'. ,. ,It OF KI�,'I \.IV +�. i. ..! 1::.. .. L•�.
I Ilk tl \•. I -190:
r r� ..
A •a
r reel of land lo cated in the
the S" of the SV-1 /4 of Section 1 11 o Townshi� 29 ~ North, R i nE 19
Ve =t. 10ti,n of Hudson, being further described as foiloas:
begbnning at the S -1/4 corner of said Section 11; thence
K69 29'G3 "t�, along the South line of the S1; -1/4 of said Section 11,
237b.39 feet; thence NO2 2P 06 "W 1322.62 feet to the North line
Of the S - 112 of the SW of Section 11; tF.E -�E S�,
said Korth line, 1445.:; fEEt to the North -icuth 1/4 line of said
fE
1325.6h fe
Section thence S00 34'16 "M, along said north - South 1/4 line,
et to the point of beg,innini. ParcEl contains 73.31
acres (3,173,674 Square feet) and sub�Ect to all easements of
record.
Together with and subject to an easement for ingress and egress
located in part of the . -1/4 of the SW -1/4 of Section 11 and in
part of the St -1/4 of the SE -1/4 of Section 10, all in Township 29
North, Range 19 West, Town of Hudson, being further described as
follows: Corr at the 5-1/4 corner of said Section 11; ti- -,
he y 29'031%,, along the South line of the Sb: -1/4 of said Sec::_..
2376.39 feet; thence NO2 26'06 "6; 1256.54 feet to the point of
bEginnini; thence continuing K02 66.06 feet to the Korth
lin& of the S -112 of the SW -1/4 of said Section 11; thence
N69 .15'50 "W, along the Korth line of the 5-112 of the SW -1/4 of
said Section 11, 179.28 feet to the NE corner of the SE -1/4 of the
SE -1/4 of Section 10; thence N69 41'39 "W, along the Korth line of
the SE -1/4 of the SE -1/4 of said Section 10, 1318.24 feet to the
West line of the SE -1/4 of the SE -1/4 of said Section 10; thence
S00 25'39 "W, along said West line, 66.00 feet; thence S89 "E,
on b line being 66 feet distant Southerly and parallel to the Korth
line of the SE -1/4 of the SE -1/4 of said Section 10, 116.32 feet
to the E line of said SE -1/4 of the SE -1/4; thence 569 35'50 "E; or.
a line bEin 66 feet distant Southerly and parallel to the Korth
line of the of the SW -1/4 of said Section 11, 162.54 feet to
tEc oint of beginnini. Parcel contains 2.21 acres (95,946 Square
Feet a" is subject to right-of-way for town road d
=uLJEct to all eascre (Scott h.oadj ar.
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