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*\~Jisconsi6Csepartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety find Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
268616
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
BRINGGOLD, DANIEL WARREN
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600318
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 51 O
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Ar f 7
Septic NA Dt Bottom 11.09+-T Y
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System Z~
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
mead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Moe Number:
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.)
LOCATION: WARREN.9.29.18W, SE, SW, 100TH AVE v,vl
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
b
~ j .,eta„ a
Safety and Buildings Division
~•■~r■r,. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P_O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 5-/--
See reverse side for instructions for completing this application State Sanitary Permit Number
•
The information you provide may be used by other government agency programs p Check IYreT.,. coy~revt,<S application
IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
5yr 1/4 1/4, S T~ , N, R 'r E (or
~~4r
Property Owner's Mailing Address Lot Number ( Block Number
/ a'1 e 42 V!4 _jp
City, State Zip Code Phone Number Subdivision Name or CSM Number 1
4.1 ~ ( _ )
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
❑ vil age U,
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF z Al /
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 41,2 -16 1;2 " 74e~14B
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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System ___System_----- __TankOnly- 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;U 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) yyf
i.77 E ~ jilp= ~1U
v ' i_ Feet eet
VII. TANK Capacity gallons Total ' # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank t @ y^ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Stamps) /MPRSW No.: Business Phone Number:
ey fo7
A2 1 46 4
Plumber's Address (street, City, State, Zip Code):
r r G~
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature am s)
Approved E] Owner Given Initial 'L/7 4-d CT Surcharge Fee)
~-2 S
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Di--ion, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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, 608-266-3815-
To be complete and accurate this sanitary permit application must include:
1. 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 8 112 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.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (tees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry,
Labor and Human SOIL AND SITE EVALUATION Q
Relations Page /of J
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
1®
Attach complete site plan on paper not less than 8 1/2 x i t Inches In size. Plan must County
f
Include, but not limited to: vertical and horizontal reference point (BM), direction and Sf" B '
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. r
Parcel D. # ~
APPLICANT INFORMATION - Please print all Information. Reviewed by Date
Personal Information you provide may be used for secondary purposes (Pdvacy Law, s. 15.04 (1) (m)). :N ST CRUD N
COiJSiTY
Property Owner Property Location
G0/1P10ti TiPUESD//~
Govt. Lot 51-1-, 1/4.5&,) 1/4,S / (or IN
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
/ao chi. A~-c . / cs y PE4jol,~J6-
City State / Zip Code Phone Number Nearest Road
~DwT 5 GU/ 5yo s 31( 715 7f j- 15 0 1 0 City El village [Town
[B ew Construction Use: U~Kesidentlal / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
f5o-
Code derived daily flow !°DD gpd Recommended design loading rate NW bed, gpd/fF _trench, gpdA12
Absorption area required LVA bed, ft2 trench, ft2
? Maximum design loading rate N~~ had, gpd/ft2 • l trench, gpd/ft2
Recommended infiltration surface elevation(s) .5-9t- P4 ..7
P4 ft (as referred to site plan benchmark)
Additional design/site consideration's/
Parent materiel SG✓r ITU~/3Q $ , Flood plain elevation, if applicable - ft
S Suitable for system Conventional Mound In-Ground Pressure AT Grade System t ill Holding Tank
U Unsuitable for system B -S ❑ U B--, ❑ u p S❑ U O S❑ u S u ❑ s
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
In. Munsell ou. Sz. Cont. Color Texture Consistence Boundary Roots GPD/ft2
Gr. Sz. Sh. Bed , Trench
d io
Ground 2
elev. ✓ J 40 v
S, S J~ Q s / D
/00_/~ft. S,~~ 4N1~5 / f O
Depth to -
limiting
factor
Gn in. ;
/v Remarks:
Boring #
Os 2 s 17 '
Ground
s w~ 7, I
elev.
97, y~ft.
Depth to
limiting
factor
y~._in. Remarks:
CST Name (Please Print) Signature Telephone No.
RoBeR7- VLORickT- 7i5= 38co-49(95
Address
6W Vd•✓ .
PROPERTY OWNER SOIL DESCRIPTION REPORT .
Page 2- of
PARCEL I.D.# GD T C-SM
Boring # Horizon Depth Dominant Color Mottles Structure D/ft2
In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
'
3 Bed Trench
d -/o /0 3 s ~ GQS S /f . 7 , 8
Ground Z 0 Z , S
110 s -3 Y4~ elev.
,ft. 0 2 S 7
Depth to 57
limiting
factor
In.
Remarks:
Boring #
-13 V V9 5IJ-
Y- 2 1319 /o w ~13 is ' s e S
3 le -6r G
round - Q S S n►'f -fC s _ i s . [o
lev.
8 7e_ ft.
Depth to
limiting
factor
in.
Remarks:
Horizon FDepth Dominant Color Mottles Texture Structure D/ft2
Munsell Qu. Sz. Cont. Color Consistence Boundary Roots
Gr. Sz. Sh. Bed ;Trench
Boring #
Aor
0 3 3 ~ s .7
Ground
elev. ~Fu y~
N 11-ft.
Depth to limiting wa y a '
.r r
factor
> ~in. Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
In. Remarks:
SBDW-8330 (R. 08/95)
D ocwp : ro? ov ' s vk vEyoiP S /
/O o "o,
O O
Bti• -4S~_~d_
ti
X30' ~5
S~ ASE : - 30 •
• = ,aAcklae PrTS ~ o
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T33 %~3,2- ~ f3
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w,p v~- T,~Fa ~ s
4 /Ohl ,D 7-eF J64 To
w
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CERTIFIED SURVEY MAP
GORDON TRUESDILL JR.
Part of the Southeast 114 of the Southwest 114 of Section 9, Township 29 North, Ranga
18 West, Town of Warren, St. Croix County, Wisconsin.
~ R /e w,
O Indicates 1" x ?4" iron pipe
/N/jV4i4X 2? c5l'
IROsON 9B, A r R 29 SE NT, l :1~,
weighing 1.13 lbs./lin. F R(] Indicates previously N A T T E D_LANDS
recorded data. - Indicates N 89 4 4' 34 E 436.00' 218. 00' 216.00'
x
~~oi 1 $di'/ TFST
T ~
I try
C)
Q LOT LO T °I
M 2. /66 ACRES 2.166 ACRES „
N
94, 33/ S0. FT, a 94, 3?/ SO. FT. J
m
LU 3 q 2.00/ ACRES EXC. R.O.W. 3 m 2.00/ ACRES EXC. R. O. W. 'r q 87, /SB S0. FT. 87, Ise s0. FT. b Q
tu
M~ r h N a♦ I
• N WATERCOURSE M
2 ROAD SETBACK LINE 0 O
I - - - - - - " 41
Z
/00' ~I
N 89 • 44 34 "f 436. 00'
O - , p S114 COR. SEC.9, T29N,
2220.60 O 218.00' 2/8.00 qq
hi 21 8.00' 436.00' 2/8. 00' ,,t R /B W, IRA IL ROAO
tm SPIKE SET FROM
R/N90.00'001;) S B9. 44' 34 "W 2656.60' b
SLINE SWI/4 RIN89.31'00"W1 /00TH AVE. COUNTYT/ES/
SW COR. SEC. 9, r P9N, R /B W,
%~\SCONS
/COUNTY SURVEYOR Is MONJ UN_PL A TTED LANDS
This instrument drafted by Laurence W. Murphy ~
•LAU EN
m :W HY': ae
Dated: September 18, 1995 t 13
N RIVER FALLS •
Owner's Address: t~9•'•• WISC. J~.
1112 100TH AVE. FQ•.LANID V
Roberts, WI 54023 ,,I4~2111l11s$%
aurenca W. Murphy
co , s•
~1 AY 2 9 199 6
~ ~,~~FGNH.WA1CA
R~~~^.,.,t of 1?
S~Gro1X
y~
5443'71 _
CERTIFIED SURVEY MAP
GORDON TRUESDILL JR.
Part of the Southeast 114 of the Southwest 1/4 of Section 9, Township 29 North, Ran^e
18 West, Town of Warren,"St. Croix County, Wisconsin.
0 Indicates 111 x 2411 !ran pipe f 31411X c5" ,BBATR 2 SEr R /a w,
X 23/RON ON M1 ~
o
weighing 1.13 lbs./lin. fN A T T E D L A N D 5
R() Indicates previously a
recorded data. m
N 89 • 44' 34 "E 436.00' 7 W
;;A A Indicates _
218.00' 218.00' J
7
W
H ti
2 4 ~O
O
W Z
Q I J
2 Z Q
" om
QI m LOT l LOT 2
y3
J N Q 4, 2
M 2,186 ACRES N 2.166 ACRES N Z
QI 3 M 94, 351 S0. FT. 7 94, 331 SO. FT. " J ~ q
WI 2.00/ ACRES EXC. R.O.W. 3 2.001 ACRES EXC. R.O.W. M m :u QI
It q 87,158 S0. FT. 87, 158 SO. FT. N q
N M V M M N I V 3
h
Q • h WATERCOURSE " Z h M
JI O ~ O QI ~ O ,
Q. O O R ~
2 ROAD SETBACK LINE O ku er V
Q. m
Z
O
' N 89 44' 34 "E ,
%00'----_
O O S 114 COR. SEC. 9, 729N,
2220.60' O 2/8.00' 436.00, g 218.00 R/BW, IRA /Z ROAD
M 218-00' M - 2/8. 00' 10 $P/KE SETFRON
R/N90100'00'1V1 S8.Q•44'34"W 2656.60' BOOTH AVE• e
R1N89.31'00"W1 COUNTY T/ESl
S LINE SW //4
sw co R. sec. 9, T29N,R18w, UNPLA TTED LANDS `,,~~~►n~~
`j '
/COUNTY SURVEYOR'S NONJ N~~~\CJ0NI.
This instrument drafted by Laurence W. Murphy
~i
LAU EN
"Revised this 20th day of May, 1.996." rn W HY
Dated: September 18, 1995 T 713 i
VER FALLS;, WISC.owner's Address: ......1112 100TH AVE. NANO Roberts, WI 54023 SCALE _ /00' O 25' 50' /00' /50' 200'
300'
nce W. Murphy
Ravi ~tarY`~~ Or
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER j-_)A N /F 1..., A /UD 7!= f1 N 131 / N Ci - Cr U C
MAILING ADDRESS / Z(:i> A5 P_;C~N .I]r'Z 3a. i~d~'fc~/ll c•~/
//I W 447 f}Uev~ue sYO/~
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE iV r
PROPERTY LOCATION -5-If 114,:'GJ 1/4, Section s T ' N-R. W
TOWN OF 1-)x,, ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste .disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
[/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year ex iration date. /
SIGNED:
DATE: $ ~'2 S~/J C
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
° S T C - 100
i
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property D!} ti f L. AND T Ati 1J ~ r N Cr is ~j L t~
Location of property ~1/4S~ 1/4, Section A9 N-R_Z_W
Township Mailingaddress /726) ,I5?,aAj De- 03(a3
/4yDSvN w S v1
Address of site l y~ ~08`' r7UQ,Y1(!P~
Subdivision name _ Lot no. 1
Other homes on property? Yes No
Previous owner of property
Total size of property 5,7 I/
Total size of parcel
Date parcel was created / i:~: Qz-
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes _A:!~_No
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Si ature of licant Co-Applicant
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Date of Signature Date of Signature
WARRANTY DEED
DOCUMENT NO.
This Space Reserved For Recording Data
This Deed made between GORDON A. TRUESDILL, JR.,
a single man, Grantor, and DANIEL U. BRINGGOLD and JEAN
E. BRINGGOLD, husband and wife as survivorship marital
property, Grantees,
Witnesseth, That the said Grantor conveys to Grantees the
following described real estate in St. Croix County, State of
Wisconsin:
Lot 1 of Certified Survey Map filed in Vol. 11, page 3107 as Document No. 544371 being
a part of the SE 1/4 of the SW 1/4 of Section 9, T29N, R18W, Town of Warren, St.
Croix County, Wisconsin.
This is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of
encumbrances, and will warrant and defend same.
Dated this 16 th day of August, 1996.
GSEAL
Gordon A. Truesdill, Jr.
STATE OF WISCONSIN
)SS
ST. CROIX COUNTY
Personally came before me this 16th day of August, 1996, the above named GORDON A.
TRUESDILL, JR., a single man, to me known to be the pees who executed e foregoing instrument
and acknowledged the same.
~qdda Poulin
Notary Public, State of Wisconsin
My Commission expires: 11/24/96
THIS INSTRUMENT DRAFTED BY:
Robert W. Mudge, Attorney Brenda Poulin
MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. Notary Public
State of Wisconsin
110 Second Street, P.O. Box 802
Hudson, Wisconsin 54016
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