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HomeMy WebLinkAbout008-1099-40-025 o ti 03 c 0 0. 0 ~ I N c t d ~ N ~ N U ~ ~ N N Z c O C € t I o 0 aNi d cc w c z LL c ID o a~ 3 E ! Q C a v o V zy ,cam \ co zw a m C', H Z o o Z V N - o I o i v In z r 1 c Z H E '2 N o 0 C cu y 7 a N ~ N N C • N N O a - I O Q z co z N Z m E N d a y G C a n o E~ Go M 3 3 3 " N°o EL V~ o •N _iaaa 1 a 0 0 ~ -j P z 1 ti ~oo ~ CD CD m ~ 1 ~ NI z ° o o V y U N 3! 7 O C E Q O M H o (D :3 C V (L °O l 0 0) `o ai a N E€ R a~i r/ w o~ m C7 o c C_ C c6 ti 0 ~ a FL- v c~ CO 1 ~ c Lo m mCl) o u', E o v • N orow tL~o z_9 z ~cn Q eC E V ~t a € a _ i~ a a • m c I c ~ II E ` ' m t A tiaM 0U)0 ` DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 553707 ~'V State atss fined) Number: NE, SE ; 3 5 , 2 8 , 16T Town of Eau Galle CONVENTIONAL El ALTERATIVE ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Co NAME F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: z Gerald Falde 6 250th, Baldwin, WI . , 54002 BENCH ~MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. E LW ST REF. PT. ELEV.: IJ6 lTPrA - itG°4✓ ~ r Name of Plumber: MP/MPRSW N County: Sanitary Permit Number: Dale E. udson 1 6629 t. Croix 135460 SEPTIC TANK/ 'f~.25'~. r~•ss~' MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: Q G ~Q o'''l✓~ e „Se? YES ❑ NO ❑ YES NO BEDDING: rNT DIA.: VIEW MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESH C v• C .O. ALARM: FEET FROM LINE: f / AIR INL T: ❑ YES NO SL ❑ YES NO NEAREST -110- a 7 0? .4 MANUFACTURER: BEDDING:-, - ---LIQUID CAPACITY: IPUMPL40,DEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN ET FROM LINE: AIR INLET: PUMP ON AND OFF) I El YES ❑ NO NE T SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: IAMETER MATERIAL AND MARKING: or excavation. (If soil can be rolled wire, construction shall cease until MAIN the soil is dry enough to continue CONVENTIONAL SYSTEM: o t = 7 S&O BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID / TRENCHES: / MATERIAL: DEPTH: DIMENSIONS T a GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DIBjFt PIPF MAT RILL,, N DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOV€ COVEa: ELEV. INLE>;: ELEV. END:7 al /Ul Pl yOPO PIPES: LINE: AIR INLET: /r FEET FROM r rj'St'D ( NEAREST RUC) > /Oa MOUND SYSTEM. o" W7;7 9 Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LAT AL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MA D MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO MBER OF PROPERTY WELL: BUILDING: COMMENTS' PERMANENT MARKERS: OBSERVATION WELLS: iAREST II__ ET FROM LINE: EYES ENO EYES ENO ' f•a~Q/~ Cvo--O dJ,ti1.~.-~ dt~» ~~f~!G~r..~2~Lt~ / ~ T. l/ Sketch System on ain in county file for audit. Reverse Side. sl RE: TITLE: SBD-6710 (R. 06/88) Zoning Administrator Tie NITARY PERMIT APPLICATION SA COUNTY Y L R In accord with ILHR 83.05, Wis. Adm. Code 114 Ez!ni STATE SANITARY P RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 7 6 G 8% x 11 inches in size. ❑ Check if revision to previous application -.See reverse side for instructions for completing this application. STATE PLAN I.D. NU BER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER ~ PROPERTY LOCATION t re/' U f-';7/0l _ AI/A__ aSGJ'/a, S 3.J TZf, N, R /,Z, 11 (or W / PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # .5,K 7_5- 0_ 7-A CITY, STATE ZIP CODE PHONE NUMBERZ_ r3 SUBDIVISION NAME OR CSM NUMBER la z C~ ; l1DC 71- 1/19 _f II. TYPE OF BUILDING: Check one CITY / NEAREST ROAD ff~~II ( ) State Owned O VILLAGE :ZG7u ❑ Public 21 or 2 Fam. Dwelling-# of bedrooms Z' PARCEL TAX UMBER ) III. BUILDING USE: (If building type is public, check all that apply) 3-511 _ % f -5 Q 1 ❑ Apt/Condo In v 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYfPPEt OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. Y~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - 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 42 ❑ Pit Privy 130 Seepage Pit Pressure 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 zv/o '?7' pp 04 Feet 90.0 Feet VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank zz, e S Lift Pump Tank/Si hon Chamber E] I El 1 11 1:1 171 1 1:1 Vlll. 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: (No Stamps) MP/MPRSW No.: Business Phone Number: Ix , Gti29 pis ti837~ Plumber's Address (Street, City, State, Zip Code): o o/ 12 a /a/LV1'12 1,elll~' IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial J L/ ` N1urcharge Fee) X / j T- , Averse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Divigion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 & 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. 11. 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% 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 (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) t' APPLICATION FOR SANITARY PERMIT STC - 100 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 rya 10 Location of property IVC- 1/4 sE 1/4, Section , T Z N-R ~l® W Township ! er~,t 17a Ile Mailing address 2514 -31,2 ~U lCl `/J ~y40 Address of site Subdivision name_ Lot number AIX Previous owner of property Total size of parcel /2~O fr,~eS Date parcel was created XZ" Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes X No Volume 7-7(9 and Page Number Z Z-2 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. ye -5-e2 y(./ ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of he County Register of Deeds, as Document No. X). Z '&L . - - Signature of Ow er Sig ature of Co-Owner (If Applicable) -`3- Fa 41 jo Date of Signature Date of Signature ;h 5~° S MAW w Jw~ y,~..}. tom' - i r~rM a~i ammoomm *=no" via, ~ deli jai !!w ai iliac i~ iiwiiie~ii iNIw~R. •.,w.: , a aw! wl+r~nir~R Mt:ofto' o sr.e. q!il► 41W K I~ _M' XS y » a (mark ~ ~ » ACZNOWLSOSUIBRV '.......Y.. l e'1'ATS Of wL00lM ..............................•-----•.cauu4 a~ pat PeeeouNly etur Mfoar ar ~1.~.. :7. . 19 a* above mama EMS MR OIP WISOONM a•1»7M.N, : i4d.)......... t. m bwwo t. be the PeeNU IF" w omw a j Mawr wws o~tnrrco w ~ t a w o do now i•~~ 7...-•-----•-- Nehry Public • iWIMPM K adaswMdAi, Beth my Comsipien is peraUalst (If Mt. gob • k• 'MMaii~ef'+IMIMrtr►alnaW b =w ttlwd► drW to tir to Manua Mbw tWr dlmatmwe „ f ~ s.. H 9 S T C'- 105 r Y H SEPTIC TANK MAINTENANCE AGREEMENT H C St. Croix County z d OWNER/BUYER /0 ROUTE/BOX NUMBER 52~ 250 Aye, Fire Number CITY/STATE ZIP 5W.") Z, PROPERTY LOCATION: NE it, S~ ~4, Section 35 T29 N, R /6 W, Town of hau St. Croix County, Subdivision Al/o Lot number. I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank lIim)er. What you put into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. C I/WE, the undersigned, have read the above requirements and agreecn to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- o ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED_4~o C q p. ll AT E St. Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION 6A8OR P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: f- SECTION: QTOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.:SUBDIVISIONNAME: NE 1/a,r 1/a 35 /TZ? N/R 1,69 (or X "a44 GG /lc N% &W COUNTY: OWNER'S BUYE 'S NAME: MAlLIN ADDRESS: S~%C'r»i X ~e r~ r 0 L-" e 6-ZSd i~ w/' S` oeZ_ USE DATES OBSERVA IONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS: PERCOLATION TESTS: .Residence -C>JNew ❑Replace A 3--30-90 3-3/-90 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ZS [:]U ,®S ❑U I S ❑U ❑S'&U ❑S LMU If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: NX O I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH MF, ELEVATION OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 01 B- / ~.OL 9Z,l l one '©Z 7!ls-/1" Z '64! a/,, 3,33*'13n meol7`o as B- Z •$j 96•Jf5' Ao e >~"8.3 ~o' '/-58Bnc~'~,G7rr~e~~ys•2> Bra B- .3 l,P,g1 9/•01 11017e >41, ~ .33 si • A331f~n ~`/'/~o' r '•Z•7.5~ mec~s B- 4.33/ 72.23 one. >,,33 .~Bls,~• /~83~ n X"~/" '.?"o /s 2,.0 B- yo-Z3 e >•83" /I G7 Bnc~'/~.S"~/s • ,2,S 177ed s B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER MCTIES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P y 75 /a 3 P- Z .Z. E io .2 iz' Z' P- 3 •/5' ne, P-_ P_ P'_, PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION g 7, 9-4 I ! ' I ` 1 i I I IN i f t . i . t _ I ~.____i_ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: le 4 sari 3 `3/ 9V ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): /3 ~i~~GgY -s'6o6 I t Zd s-. rn "ra al, ki, CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - L INSTROCTIONS FOR COMPLETING FORM 115- SBD 6395 To he a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate, whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this anew or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs - Coarse Sand Perc Percolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is - Loamy Sand > - Greater Than *sl - Sandy Loam < - Less Than *1 - Loam Bn - Brown *sil - Silt Loam BI - Black si - Silt Gy - Gray *cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay wl - with sic - Silty Clay fff - few, fine, faint *c Clay cc common, coarse pt Peat mm - Many, medium m - Muck d - distinct p - prominent HWL - High water level, Six general soil textures surface water for liquid waste disposal CAM - Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary Kaermit. The county or the Department may request verification of this soil test in the field ~Iiol _,t .;SUanc:e. A complete set of plans for the private sewage system and a permit applicafi.m r'~ust he sr . ni'tted to the appr()priato local authority in order to obtain a permit. The sanitary permit mast t)e ot)tairrr"d and posted prior to the start of any construction. J a •Ca 3 a -4 [ ~ ~ M I o~ l Q %J M 4 > QK 3 t I % Q v J +3 ti "n o i 0 %j h k n 4? 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