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ar/�n�S TOWNSHIP JL)A� SEC. ($ T `fi N, R g W
MD RE S ST. CROIX COUNTY WISCONSIN. —
JISIONr LOT LOT SIZE (:S ,go,Fy
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Zap 5z� Wo
• ; -
6
' TANKS) MFGR. CONCRETE T
NO. of rings on cover 7 - Depth p DRY EEL
,NCHES NO. of width length area
3 no. of lines width Z1 length /
Z � g area �,�S/1W
r depth to top of pipe ? 9 —
REGATE - ��SL u �yu� �►ao(aul�sk �,af L°"3,4 nD ynwk.ro A Croce3
-;R RATE_ AREA REQUIRED C a• AREAS BUILT_
, ;claimer: The inspection of this system by St. Croix County does not imply complete j
_pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
Aem operation. However, if failure is noted the County will make every effort to
- ermine cause of failure.
�'ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
'INSPECTOR
DATED a 4 PLUMBER' ON JOB;
LICENSE NUMBER
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.i.tany Penm.i.•t
State S e pJt.ic ,,i =
NAME -lf ` fL % _ ,, �� rownehip C .; "< St. Caoix County
Locatiox Section
SEPTIC TANK
Size � gatton-s. Num b Compantment.6 I
Diztanee Fnom: We.2.� -. 70 bers 6t. 12% on greaten zZope 6t
Bu.itd.ing bt. Wettands
H.ighwaten
DISPOSAL SYSTEM
D.i F kom: wetz 12% on great AZo e
p �
Buitd.ing st. Wettands F t.
H.ighwaten S.
FIELD DIMENSIONS:
Width o6 tnench Depth ob ro below Cite — in.
Length as each tine 6 6t. Depth a5 rock oven Cite_ Q--- .i n.
Numben , o S tin z ' Depth o6 tit e b e.2ow gnade21 ().in
Toa2 2engh ob tines e 6t. Shape a6neneh in pen 100 6x.
D.i.a xanee b etween t ine.6 Depth to b edna ck — 6t.
Tota.0 ab a r ea_ 6t Depth to gnoundwa 6t.
Requited area 6t2 Type oA Coven: Papers n Straw
PIT DIMENSIONS:
Numben o6 pits Gnave.0 around p.itz ye.6 no
Outz ide d.iamete t. epth beZow .intet
Taal abz a a 62 , 2
Area quike 6t2 rn
INSPECTED B TITLE
APPROVED ,DATE 197
REJECT D ,DATE 19 r
EH 115
• _ WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
�REPORT ON SOIL BORINGS AND PERCOLATION TESTS
�
LOCATION: N '/, � ,, Section ✓ . TA, R LeE (or) W, Township or Municipality
Lot No. , Block No. County
/ Su division Name
Owner's Name: �Pc/ T�
Mailing Address: /J,b e,— S
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS / ,��2 — ?- PERCOLATION TESTS Jam'^ 79
SOIL MAP SHEET U SO L TYPE ZG 7r �774t�-^
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME
CHARACTER OF SOIL DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P - 3 1
P -3 b I l iJ 1/ ,
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B c5
7 2
B .0
5 7'�.
PLAN VIEW (Locate percolation tests,soiI bore holes and suitable soil areas.)
Indicate on the plan the location and square f et ui able ar as. ndicate numb r of square feet of abs jf n area
needed for building type and occupancy. +Ste le
or distances. Give horizontal and vertical reference oints. Indicate slope.
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PL13 67 State and County State Permit
4 Permit Application County Per
for Private Domestic Sewage Systems County
* DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY
/ Mailing Address:
OCATION: f
B. L J,t,' /
_.� '' /a, Section T_ N, R (o0 W Lot# City
Subdivision Name, nearest road, lake or landmark Blk#
Village
Township ulAri' L h
C TYPE OF OCCUPANCY 'Commercial *Industrial *Other
(specify) *Variance
Single family -4,f:::�j Duplex No. of Bedrooms No. of Person
D- SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Steel (./
New Installation Replacement Fiberglass Other (specify)
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area
New Replacement Alternate (Specify) sq. ft.
Seepage Trench: No. of Lineal / Ft. + Width Depth Tile depth (top) No. of Trenches
Seepage Bed: th Len
9 Width Z-; _Depth A�Tile depth (topL--fi9ZLLNo. of Line -
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 3
Distance from critical slope
WATER SUPPLY: Private Oe Joint ❑ Co ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil Tester,
NAME _ - -� I / /
'1 �s r a
obtained from �+�� C.S.T. # ! - Z - 3 and other information
Plumber's Signature r (owner /builder).
Plumber's Address
MP /MPRSW# l� �' Phone # Ay 6
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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�RS^p'9
ST. CROIX COUNTY ZONING DEPARTMENT..
AS BUILT SANITARY REPORT
CC
Owner <r:
Property Address
S art,
City /State �� sr crjc :x '
COUNTY
Legal Description:
Lot Block Subdivision/CSM #
''V., Sec. f �-, T,91N -R _ L2W,Tow n of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: y I �
Tank manufacturer Size ST/PC 0 l o0r! Setback from: House Well PAL
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLy)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: Width Length Number of Trenches
Setback from: House : e Well 7 e P/I, Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation CIO, 00
Description of alternate benchmArk Elevation
Building Sewer ST/HT Inlet Z 0 O a ST Outlet 9 9, / PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover t✓J/ %� ,
Distribution Lines () () ( )
Bottom of System () () ( )
Final Grade () () ( )
Date of installation I / Permit number . State plan number _ 1
Plumber's si nature License number 3 - SK Date& / S7 3/
Inspector���(
Complete plot plan �+
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety-and Buildings Division INSPECTION REPORT y S T. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarlN%V' .:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
P
J VfYA8a m VRED & LINDA I wyia f Ilage ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev l BM Description: Parcel b ?0"- 1039 - 80 - 000
vv 0
TANK INFORMATION ELEVATION DATA A9800516
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 000 Bench � 5 )-y 10 100
Dosing
3f fywyl
Aeration Bldg. Sewer
Holding St I Inlet
5-
TANK SETBACK INFORMATION �tl W Outlet S q 6_
TANK TO P/ L WELL BLDG. q jntake ROAD Dt Inlet
eptic f wr NA Dt Bottom
Dosing NA Header / Man.
Aerati NA Dist. Pipe
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. li Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
LEACHING Manufacturer:
INFORMATION Type of CHAMBER mo Numb
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
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.)
LOCATIO WARREN 15.29.18.234A,NW,SW 1222 US HIGHWAY 12
.l (:� �. ��i (-f — 1 Wl✓� Crl G 1cll �C l {. �! ' �l([' ee'l
Plan revision required? ❑ Yes V No
Use other side for additional infor ation. F17TT%Js /
SBD -6710 (R.3/97) Date Inspect 's Signature C ert Nn
NV Isconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
In accord with ILHR 83.05, Wis. Adm. Code P O Box 7
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County //' C V than 8 112 x 11 inches in size. U' D% X
• See reverse side for instructions for completing this application State Sanitary Permit tN Number
Personal information you provide may be used for secondary purposes E] Check if revision ro pr�vidGsica n
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
; h Ece S tN 1/4 SGI 1/4,S S T A , N, R 1 E (or
Property Owner's Mailing Address Lot Number Block Number
2 Z /
City, State Zip ode Phone Number Subdivision Name or C519 Num r
a �v jlTl 5 - - >7y9 -���'7 O
11. TYPE F B I ING: (check one) E] State Owned � �OIE rest Public 1 or 2 Famil Dwellin - No. of bedrooms -� Nearest Road
o � �/`
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0 ;:?, — /a 3
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 lin line B, if applicable)
A) 1. ❑ New 2_ ❑ Replacement 3 replacement of 4_ E] 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
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Feet Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturers Name Con -
New Existin strutted Concrete Steel glass App.
Tanksl Tanks Kf
epticTa r Holding Tank MQ `
Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Pit er's Name: (Prin Plumber's Signature: (No tam ) MP /MPRSW No.: Business Phone Number:
A FAY - Y X, lum er's Address (Street, City, State, Zip Cpclek IF
IX. COUNTY / D PARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued suing A t Signature (No Stamps)
10 Approved El Owner Given Initial 1 �/ Surcharge Fee) l
Adverse Determination tP /o0 �f
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.1 DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
J� 1 IVI• aa�.a �•-
t5
Cc Labor and Human Relations Wis. Adm. Code COUNTY
Divisior:of Safety & Buildings in aCCOfd with ILHR 83.05,
PARCEL I.D. #
Attach complete site plan on paper not less than B 1/2 x 11 inches in size o of slope, sale or
i nclud e, but Ufa _ 3 9
not limited to vertical and horizontal reference point AL INi� -.., RE/IEWEO BY DATE
dimensioned, north arrow, and location and dist e o � l '
RMA� •�
APPLICANT INFORMATION— PLEASE ROP ER LOCATION
PROPERTY OWNER: W Cc ! OVT. LOT 1/4.W 114,S S T .Z9 N,R
,
J_e T # BLOCK # SU80. NAME OR CSM #
PROPERTY OWNER':S MAILING ADDRESS ST. CROix+ ' Clr,{ OVILLAGE NOV NEAREST ROAD
a Zip CODE 7 y _10 2 I?
CI ATE Sod �3 \
r 3 [ ] Addition to existing building
( ] New Construction Use [ ]
Residential) Num
Replacement(S* --f KJ [ J Public or commercial describe —bed gpd/� , g _ trench, gpd/ft
Code derived daily flow r gPd . 9P� ft . 8 trench, gpdj�
2 '( trench, ft MaAmum design loading rate _
Absorption area required �o� bed, ft 0 ft (as referred to site plan benchmark)
Recommended infiltration surface elevation(s) ft
Additional design / site considerations SP+2 Flood plain elevation, if applicable
Parent material I SYSTEM IN FILL � S N � �K
CONVENTIONAL MOUND IN-GROUND PRESSURE � S 0 ®U S ® U
S= Suitable for system m I ®S r U I n S ® U
I
U = Unsuitable for s
SOIL DESCRIPTION REPORT GpDlft
Mottles Structure (Consistence Baz�N Roots Bed Mend
Depth Dominant Color, Texture Gt'. Sz. Sh.
Boring # Horizon in Munsell Qu. Sz. Cont Color S 3� A) P 3 '
z
' 4 /
I
Ground 3 39 7, e 5�
R
Depth to
limiting
factor
Remarks:
Boring #
Ground
qjj n SU
Depth to
limiting
factor
Remarks: Phone: S ,
CST Name: — Please Print o
ddress: Q , s � /sG Date: / CST Number L
Signature: /
Characteristics of septic s stem
1) Steel septic tank is deteriorating
2) Septic system 20+ years old
3) Conventional bed system, approx. 18'x 30'
4) 3 bedroom house
The purpose of this soil test is for a replacem
s g � holes tank that has deteriorated. We du two bor o e steel
backhoe, one at the end of the system, the les with a
corner of the system where we encountered the on the southwest
could measure the depth of the system. sewer rock and
Boring #2 was not logged because as we broke into the side of
the system sewage was leaching into the bore hole. Direct
measurements from the ground surface determined that the
abrupt sand layer began a 35" from the surface. The botto
the rock was at 45" and top of the rock at 29" from the m of
Boring #2 verifies that the system had been installed in he sand sand
layer. Boring #1 confirms the three vertical distance of suitable
soil for today's standards. Soil boring
layer of finer textured soil over an abrupt s identifies a mottled
o
this mottled layer is greater than 12 p coarser texture soil,
, which reflects today's codes.
Per phone conservation, on September 23, 1998 with Rod
Eslinger Zo ning Assistant St. Croix Count ' y nines office, we
discussed this mottled layer. The consensus was that it is a
existing system 20 plus n
Years old, the system is not failing,
system appeared and the
that it had been installed in the sand layer, and
soil boring #1 confirmed a 3' separation of suitable soil below h
layer the
system, that the mottled la
Y greater than 12 would be
acceptable.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
OWN CER� CATION FORM
Owner/Buyer
Mailing Address
LW / "Z
Property Address -..
(VcrifrcaGoa
rcquirrd
�J� /�! ��((� �Om Planning t for new Co
- Czty/State ���� W� astruction)
Parcel Identification Number — �O
NGAL bESCR'TX
Pfoperty Location /V lU <, S
<, Sec. TAN -R"W, Town of
Subdivision
Qt tified Sate Lot #
. _ ey Map # /�Q /�
Volume
Warranty Deed # Page #
j 3 Volume 9 /
SPCC house ❑ yes Page
Lot Bars idcnff ble Ltl ycs ❑. no
nCCOf
of pmmpin out me septic � ooulldtes*mia . .
race affect Ere AMC6= of tie scptc tankeu: or s°°°cr if add bq I per
the waste,
p 1?P' owns agree t .�
a�
is is P pinmbcrort catiaaform, sig�od bY.the oanecandby. a
estea
oP�mg condition andloc(2 sRa • �y� that (1) �e onaite ���sposai
nzspoction and pamping.(if II i 0 °�Y). the scpti�c.tankis less $race 113 tull of shrdgc.
_ Ilwo, tlde dbaheatad tfae
� fob• pia. as set by de aced arai aI system is the private fge em widL the staadatds
gthatyonrrscpdc aoean d"D of (
days-of the thine y,� motion dau. d be completed and tee to the State of W_ ccwficahoa
'bocce
C�vix- CocmtY Zoning Office within 30
SI TAE ANT
DATE
OW MCATxON
I (we) oatify that all statanwis oa this form are true to the best of my (0t r) lanowl
moots Od in Register of Doods p �. I (we) am (arc) the ownez{s) of
above, by virdre of a Wart" deed
ATURg ���• n /..S�/ `18
« «s « «« Ally infotmati DATE
on that is M s4Vreseatcd may temtt is the sanitary pe mit being revoked by the Zonin eat.
ss Indude with this a nmg Depactm sss«s.
PPlieation; a stamped fit, dood from the
a Copy of the CcdWod tury if re f Mace c Deeds ofEce
e3' map mfencace is made in the warranty deed
DOCUMENT NO. W AINL A AWY OS &0 A ?"16 erACt atsCRVEO rOR 01COROM0 nATA �f
4'73343 STATE B OF WU"NSIN FORM 8 — JM
914mc 37 I'
REGISTER'S OFFICE I�
l Ervin C. Nielsen, a single man
ST. C�OiX Co., i
- - - - - -- -- .... -- • •••-- •......... ....
__ .................. -- -- -- .._............ .. .... Read for Record
I - .... .................... . - -• ........ --- --- - - - - -- -- ...._....................._.. i. SLr0619�1 I
......
c ve •s and war an • to a I.in I 1 : 30 P. M
e� a
"�o>j`rdeans �u. Rd and wife as - - siiimr7ii flip: marital
P't'D . .. - •--- -• - - -- • - - - - -. �ol+rafOMd�
-- -
................ ................ .................................... .
-
..... ...... .... .1 ....................... -.. .... ,.i
- .
.- _.._..- - - -_.. _. . .................. .
the following described real estate in ......Sta_.�_ ..... ............ .(,ounts,
—; !
State of Wisconsin:
A parcel of land located in the SW Ik a& the SW h and in the Psra1 No: ..............................
of the SW h of Section 15 T29N
�4 of
Wisconsin, mare fully described asfo,lloidS St. Croix County,
Cam>encing at the SW Carne_* of said Section 15: Ttlence NO�i a the West line of
the SW h a distance of 1336.50 Itwnoe S89 °45'20 "E 280.50' to the point of beginning;
Thence NOM 463.28' to a
point an the South line of the Certified Survey recorded in
volume 5 of Certified Survey Maps, p age 1308;
Thence S89 0 45 1 20 "E along said line 489.50
Thence SOME 460.00
Thence S89 °45' 20"E 142.00-;
Thence SOUM 1335.69 Y"
Thence E89o59'15"W 66.00
Thence NOWH 364.00
Thence S89 265.00',
Thence NOAH 375.00'; ��
Thence S89 300.50 'Si
Thence NOM 596.24' to the point of begi nirlg.
This -. ... :Ls -not homestead property_
(Xt (is not)
ExceRtion to warranties: together with and Subject to any o ther eases rents, Cv�7P.nants,
reservatrons or restrictions of reccwd, if any, but this shall not br_ Mme; t,-, i_xtend
�Y such oar recorded encwbrances beyond the terns established by law tiler-of.
Dated this . .- _-- --- - -.. day of 6 1 111 ght 91
(SEAL)
Ervin C. Nielsen
. - (SEAL$
(SEAL)
Y
AUTHRNTICATION ACHNOWLBDGMBNT
Signature(s) Ervin C. Nielsen
-- -_- - -- - -- ------ --------- - -- STATE OF WISCONSIN
------- ----- - --- ----- ----•- -•- -- - --- ss
id - ---- - -------------------------------- County.
authentica�� 83 o --- -- I! — Personal! came before me this --- ---day of
Y
....... 4...... - - 91 - - - - - -- - -
e� 19- the above namel
Hugh F. Crain ... ---- - - - -•- --------- - - -• --
TITLE: MEMBER STATE BAR OF WISCONSIN _,
authorized b y 1 706.06, Wis. State.) -- - -- ------ --- - - - -- -•-------- -
to me known to bu the person .__- ....__ who executed the
fo reaninn inuf.,,.,.e..♦ .,..a ....�__...._�__ a-
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