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HomeMy WebLinkAbout020-1374-13-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety ar,10 iuildinq Division INSPECTION REPORT Sanitary Permit No: 430608 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: S'ostedt, Sven & Christina I Hudson Township 020 - 1374 -13 -000 CST BM Elev. Insp. BM Elev: BM Description: Section/Town /Range/Map No: /t C , . e tc = I � . � -, _ . /3 % - z d ( 12.29.20.2246 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark / Dosing Alt. BM r ;- Aeration — Bldg. Sewer Holding — + St/Ht Inlet i TANK SETBACK INFORMATION St/Ht outlet HS T TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. 17.71 Aeration Dist. Pipe h . ?'1 97 54. Holding Bot. System (7= PUMP /SIPHON INFORMATION Final Grade Manufact rer Demand St Cover GPM f✓ /vi Model Number J qt _ 10 TDH Lift Fric ' Loss System Head Forcemain L th D _____ SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: r+ i UNIT 3� 7 Model Nu DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia t.' Length Dia Spacin SOIL COVER c x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched "A, Bed/Trench Center l ' Bed/Trench Edges Topsoil ( Yes `j No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: // f Inspection #2: {-vt ivy Location: 236 Starr Wood Hudsop, WI 54016 (SE 1/4 SW 1/4 12 T29N R20W) Starr Wood Lot 13 Parcel No: 12.29.20.2246 1.) Alt BM Description= , L" 2.) Bldg sewer length = A - amount of cover 7 Plan revision Required? ��, .. Yes o Use other side for additional information. 1 f _ -J �_ / �` ' � — 4 SBD -6710 (R.3/97) Date Inse or's Signature Cert. No. i Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 , SCO/I SIII Madison, WI 53 ^ C IV Lary ermit Number (to be filled in by Co.) (608) 266 -3 51 l�G umbe Q �0 Department of Commerce Sanitar Permit A p p lication state PI LD. - N umbe r y pp DEC 1 2 003 a In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(l)(m) ST, CROIX CO A dress different - than mailing address) 936 I. Application Information - Please Print All Information Property Owner's Na me O # Lot # Block # ��] A A _ Property Owner's MM ailing Address c� Property Location 02 J,E ',d , J�,/ 'k , Section City, State Zip Code Phone Number J / s6� dad' / /// q 9 (circle one) T. io �t c- n/. ` T o` N; R o2,0 E otQ II. Type of Building (check all that apply) p� S w 1atM . 1 Subdivision Name CSM Number ® 1 or 2 Family Dwelling - Number of Bedrooms S ❑ Public /Commercial - Describe Use o ❑ State Owned - Describe Use ❑City_ ❑Village ®Township of /y p III. Type of Permit: (Check only one box on line A. Complete line B if applicable) o � p — �j 13 bm A ' 19 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. El Permit Permit Renewal ❑ Permit Revision Ch an g e of ❑ Permit Transfer to New Before Expiration Plumber Owner 1V. T of P )WTS System: (Check all that apply) ® Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed f) System Elevation A >v -tP0 96.60 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site t r Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks W - Septic or Holding Tank _ oc S J Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si nature MP /MPRS Number Business Phone Number Plumber's ddre ss (Street, City, State, Zip Code) VIII. County /Department Use Onl NA Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is uing gent Signature ( Stamps) r � Surcharge Fee) ❑Owner Given Reason for Denial 2-6D-- Ogg, IX. Conditions pprov Dim ppit oval SYSTEM 0 - 3) 1 Septic tank, effluent filter and aU gZ�Ir" 6_+ dispersal cell must all be allilylged /�mainteined - as per management plan provided by "I inbif, - Hwke- . 2. All setback requirements must be ma in tained q as per applicable Code/ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) F 4e + . ire . PLOT & CAM SECTION PLAN ZAPPA 6803• EXCAY� IW Io�1AAlti�i �A,eAc r " PF"CT co AAA Ayr 13 �� S�oSr�DTS t 14 8jfbRoo 1i' d G�CF! G8 l ` < E * AiC '�tweR der➢ lseACH HARK — N ' AIL MJ � "f Lr► � � Sc 46 � 3 1��� E[�rl. _ Mao!"' /;2,4—b GA Lj ,E3iEQ StFv,c +�a• A,8'vo fycrLp lu lit JrA<m F_A1® Aga E Ar. AooLA o py �a A gq SCAL _) L.- � �w1U�/.Yfi4Qlr /`�/1(L /N /O C r4 der OA5ERV, -1770••1 P, Pd- ©&l AC /14T) 0� O fZ Memo: VEN T e—A p uc mu: "L ' ? �NtSI{L OATS: f8 ��� .solLt�s�N46v: The Stand din It for Chamber Ate 7 f" ' �,� at Letcfwng T 8o'frgm Cav Av0Ar 17 a � SIoE view 75' Effective Length ..PLO 67- f PLOT & CRoss socnoN PL Am y1PPA w". EXCAVATM INC PIAMBING UNIT gym' rEDT!5 ;o a4 �o AjC S4,vok d erDL' • ^• " �•- �tJdc?d v�1>e — � �![. NJ �'' f � o —' � �c w rrr� �z& && A o goo 6 c •tip � u 4`Puc Fjg*ruc&jT 41NE Fee..; Ji.4cm &No N Q"6 ZA +10 7 A — L� &,ocJj,p4 ,r— ^ AIL 1A1 /o" C .,f Z47 A%/A-C' " Po PC ©dj&C4o,r1 Oft SIGNED: or VENT hP Uc:ENSE' a a� - G � i2 e soIL1ESOr: T I It or Chamber J OA The Standa d n t Vey v 1' Overlap at Latching - _. : -- j T�� Bo'1r..n �t� Pcq Sac�K'l 12° F A o � 6 6BEE M E SrOE View 75' Effective Length Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County C01 x include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION &fKcondgr a ipr tion . iewed by Date Personal information you provide may be u - pu se s (Prr y y J , s. 15.04 (1) (m)). _ PGC 17 Property Owner Property Location 7 0 7 a -- Govt. Lot S IC 1/475UJ1/4,S [ T r ,N,R a E (or) W Property Owner's Mailing Address', c> ee (k { – Lot # Block# Subd. Name or CSM# T w l� f S - T� � tE;r.�ooD City State ' ; �o,(e >,,,tTPh9r_M:W El C ity Village Town Nearest Road > �V'? - New Construction Use: ® Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow d!<QD gpd Recommended design loading rate Ds bed, gpd /ft 2 _AQ—.(— trench, gpd /ft Absorption area required c.> bed, ft a ;, p rench, ft Maximum design loading rate 0, S bed, gpd /ft 0 /_ trench, gpd/ft Recommended infiltration surface elevation(s) %, so ft (as referred to site plan benchmark) Additional design /site considerations IC _ -I Aj L pryil` f Qk 1 V INQQ' 4L Parent material 6 Li4Ct A L _rl LL Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 6 S ❑ U I� S❑ U [K S❑ U S❑ U rM S El U El S Oaf U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft <<: in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench cr all mom -34 > - 41 4 M A I c Z 4),1 C Ground > 7,S'y �, J 1'h s �'t ` 7 % lev Depth to li im miit ii ng ' 96 .(00 i in. 1 21. !o (o R , Remarks: Boring # o-k /o`3 � i L 1 6 A Q s ... Ground 7, SY e 4 e s . c S o m:6 l .SY 4 _' 63 Depth to limiting factor ;P in. Remarks: CST N a me (Please nnt) Signat re Telephone No. I�Q N 3 Z - 6 - AdMss � � / Date CST Number N 6- /Z- 60 2 7S7 of PROPERTY OWNER SOIL DESCRIPTION REPORT Page ;2 • 3- l PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Z A 6 -3 1 6"Ik3 l 3 -43. IMP M S / 0 77 ;0 Gro und r �_ Depth to � I limiting 9 (DD ' f�c�or in. 2 Remarks: Boring # 3. B -q �o� 3 �-- SG r, M �s 1 n. o o g g � � 7,SYjR -- C, nos ri , LS ,� p Ground J "7 Q 4-13 'S) L. I ru Mir CS oil elev. Nft. d- d4 +/4 _ 5 G A, 5 /m Depth to limiting o fa, �for 'l Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # (, 6 :4, 2FS i 3 SG M n , ] CS 2 6 7 0 1 7.SYk 56 1 CS O.S o b Ground 7.SY 3 Sic I rn sbk Y / G C S a;. '0,3 'e 91 7 - ft. 6 4 4 7-4 3 7. 5`10, PS � ®, Depth to IQ`1R 4 33 S-6 M 5 7 :6, TS frl � � limiting M in. in. Remarks: Boring # t Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) I i t i I r I /6 Y i Z,�P� 6 3 l LAJ I r r� N v�Cti1 I � � d COkV NhVtC 54L G�l POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pape % of .�. FILE dNFOOkATlON s rism sPE F" Owner �^ J`� -Septic IGN Capacity 125 D NA Permit d 2 © Mewfacturor Wieser O NA DES PARAMETERS Zable O NA Number of Bedroome 4 O NA Effluent Filter Model A -1800 O NA Number of Public Facility Units OVA Rump Tank Capacity ga i D NA Estimated flow (average) 400 Govday Pump To* Manufactuer D NA Design flow (peak). (Estimate l x 1.5) 600 asilday Pump Manufacturer D NA Soil Application Raw .7 ay /W Pump Model D NA Standard Infkueaut/EfflueM Qus" Monthly oversge• pretreatment Drat DNA Fats. Oa & Grease (FOG) 930 mg/L D SwmUGrsva filar O Pest Filter Biochemical Oxygen Demand IBOD SM MOIL O NA O Meduniod Aeration O Welland Total Suspended Solids (TSS) 5150 mg/L O Disinfection O Other. Pretreated Effluent Quality Monthly average Dispersal Cents) O NA Biochemical Oxygen Demand (BO J S30 ng/L O In-Ground (gravity) O krGround (pressurised) Total Suspended Solids (M) S30 mg& O NA O At -Grade O Mound Fecal Cooform (geometric mean) 510 cfu/100ml O Drip -Line O Oche: Maxomm Effluent Particle SIM Ys in dia. O NA ®NA Other: ' >XIA Other° N NA 'Values typiasl for domestic wastewater and septic teak effluent. Other: ® NA MAINTENANCE SCHEDULE Service Service Evart Frbaurency inspect condition of tank(s) At Naar once every: 2 ® VW A S ) a 3 ) O NA Pump out contents of tankls) When combined sludge and scum squab one-third US) of tank volume O NA O month andrrMMM s) g ym ) O NA Inspect dispersal ceg At bast once every: 2 ($) s) mon Clean effluent finer At least once every: 61 .1 ® th(d DNA Inspect pump, pump controls & alarm At least once every: O n!%* ) ®NA Flush laterals and pressure test At bast once every: O moe s ®NA Other: At least once every: O mcn GIs! R NA Daher. R NA MAINTENANCE INSTRUCTIONS Ecer+ses or certifications: of tanks and dispersal cos a" be made by an individual carrying one of the following Master Plumber: Master Plumber Restricted Sewer POWTS Inspector: POWTS Maintainer: Saptage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware. identify any cracks or balese manure the volume of combined sludge and scum and to check fat any back up or ponding of effluent on the ground surface. The dispersal cells) shall be visually inspected to check the effluent levels in the observation pipes ands for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing and ro*dm the immediate notification of the MCA regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third ()S) or nova of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113. Wisconsin Administrative Code. AN other services. incwbV but not limited to the servicing of effluent filters, mechanical or primed oompormts. pff"011U It units. and any sevicing at Intervals of S12 Months, sho be performed'by a mortified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of eompbtion of any service event. GMW 14/01) Page - 4. of START UP AND OPERATION th For new construction. Prior to use of e POWYS check treatment tanklsl for the presence of painting Products or other chemicals that may impede the treatment process and /or damage the the dispersal cells). If high tcentrad"M are detected have the contents of the tank(s) removed by a septsge servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks niay fill above normal highwater levels. When power is restored. the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the cells) and may result in the backup or surface discharge of effluent. is Sn pump or contact a Plumber or POWTS Maintainer to assist manusly operating t controls r the pump t pow to the effluent pump pow restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cal �.rp� area. or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-g Reduction or elimination of the following from the wastewater stream may improve degreasers: e and prolong the life of the diapers; disinfectants; fat; POWYS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs, foundation drain (sump pump) water,' fruit and vegetable peelings; gasoline; grease; herbicides; most scraps; medications, oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and /or is permanently taken out of service the oWis fllowing t ps she I strsthre Code: insure that the system is properly and safely abandoned in compliance with chapter Comm • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • Th contents of all tanks and pits shall be removed and properly disposed of by a Septege Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filed with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWYS fails and cannot be repaired the following measures have been, or moat be taken, to provide a code compliant replacement system: has been evaluated and may be utilized for the location of a replacement soil absorption )R A suitable replacement area system. The replacement area shook! be protected from disturbance a wel� p F ailure n to protect replacement area will lot Ines and required setbacks from existing and proposed structure• suitable replacement aroa. Replacement systems must result in the need for a new soil and site evaluation to estab a comply with the rules in affect at that time. 0 A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWYS technology a holding tank may be installed as a last resort to replace the failed POWYS. The site has not been evaluated to identify a suitable replacement area. U area is available Thle a holding tank If no replacement e re lacement area. evaluation must be Performed to locate a suRabl P may be installed as a last resort to replace the failed POWYS' s may be reconstructed in place following removal of the biomat at the p Mound and at -grade soil absorption system infiltrative surface. Reconstructions of such systems must comply with the Hiles in effect et that time. < <wARNiNG> > NOT SEPTIC. PUMP AND OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES' DEATH INSU RESULT' RESCUE OF A ENTER A SEPTIC, PUMP OR OTHER PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE- AD NAL COMMENTS POWTS MAINTAINER POWYS INSTALLER fPh C ounty Ben Morgan Name othe ) 715-386 -213 Phone 715 -386 -285 SEPTAGE SERVICMIG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Tri County Ben Morgan) Name St. Croix County Zoning Offs e Phone 715- 386 -46 Phone 715-386-2130. vwonsin Administrative Code. & and 83.5411). (2) s►131. Thi d was draped in compliance with chapter Comm 83.22(2)(b)(1 1(dl (fl ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBu er ''1 ✓� J C � . Y D Mailing Address P' V , 8 012- S1- PG U E /V SS 1 6 Property Address (Verification required from Planning Department for new construction) City /State e11 S W Parcel Identification Number 6 S 19 ' IDD D LEGAL DESCRIPTION / Property Location Sc %4, X W %,, Sec. /-g , T 29 N -R - W, Town of 8 ' 4 �0 /V . Subdivision Sic wo o ,Lot # 3 Certified Survey Map # Volume , Page # ar Warranty Deed # —�_ ���- . Volume 2 �� . Page # Spec house ❑ yes no Lot lines identifiable yes ❑ 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, journeymanplumber, restrictedplumberor 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. Uwe, 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. SIGNATURE & APPLICANT DATE OWNER CERTIFICATION I (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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * ** Any information that is mis- representedmay 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 U 2966P 115 k` STATE BAR OF WISCONSIN FORM 6 - 2000 KATHLEEN H. WALSH SPECIAL WARRANTY DEED REGISTER OF DEEDS Document Number I ST. CROIX CO., WI This Deed, made between Landsted LLC, a Wisconsin limited RECEIVED FOR RECORD liability company 12/02/2003 11:15AK WARRANTY DEED Grantor, and Sven O. Sjostedt and L. Christina Sjostedt, husband and i >;EMf ' It wife REC FEE: 11.00 TRANS FEE: 267.00 Grantee. COPY FEE: Grantor, for a valuable consideration, conveys to Grantee the following CC FEE: described real estate in St. Croix County, State of PAGES: 1 isco (the "Property") (if more space is needed, please attach addendum): LOT 13, LAT OF STARK WOOD THE TOWN OF HUDSON, ST. RO COUNTY, CONSlN. Recording Area Name and Return Address Valley Abstract & Title, Inc. P. .1 149 H son, WI 5 Together with all appurtenant rights, title and interests. 020- 137413 -000 Grantor warrants that the title to the Property is good, indefeasible in fee Parcel Identification Number (PIN) simple and free and clear of encumbrances, arising by, through or under This is not homestead property. Grantor, except: (is) (is not) Easements, covenants, restrictions, and rights -of -way of record. Dated this _y day of November , 2003 LANDSTED LLC By G� * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )Ss. ST. CROIX County ) authenticated this day of , Personally came before me this day of November 1 2003 the above named s Landsted LLC, a Wisconsin limited liability company, By TITLE: MEMBER STATE BAR OF W140 00 W (Mi'tt'at.: to me kno to b rson s who executed re oin (If not, C " f ¢O g g authorized by § 706.06, Wis. Stats.) .• • instrum t and !edged the sam fy THIS INSTRUMENT WAS DR lfpd) H I' b� ��H 1-• Brent R. Johnson - Lommen, Nelson, Cob¢ 8y Stagebe�. '�� � ion date ''•., _ No Public, Sta te of WISC Hudson, Wisconsin _ My Commission is permanent. f not, tate expirat (Signatures may be authenticated or acknowledged. 11 tare , ) * Names of persons signing in any capacity must be ed below their signature. SPECIAL WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 6 - 2000 INFO -PRO (8W)655 -2021 www.intoproforms.com ... ..� 1 s e f w M,w AV VT CA 10 i N t i te , �ww ,o 1 r 14 - '66'i — M-- .r i �t + 9p 1 F7 s / i 1