HomeMy WebLinkAbout026-1143-90-000 County:
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division + i
INSPECTION REPORT Sanitary Permit No:
453013 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:
Conway, Scott I Richmond Township 026- 1143 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
20.30.18.1050
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark —
Dosing Alt. BM O 16 S / 1� ba 97 4
Aeration Idg. Sewer
5. �'► 5',�P3
Holding - - -. SUHt Inlet p
TANK SETBACK INFORMATION St/Ht Outlet .✓af
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic �5 �� Dt Bottom
Dosing Header /Man. Q. V
Aeration Dist. Pipe
Holding Bot. System
/D . 7 U
Final Grade
PUMP /SIPHON INFORMATION ,
Manufacturer Demand St Cover
GPM
Model Nu er
-
TDH it Frictio System Head � 7DH ,
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Len No. Of Trenches DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
ENSIONS
✓ � 5
DIM
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: -
INFORMATION CHAMBER OR
41 Type Of System: � / / UNIT
Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
it Pipe(s)
Length U/ 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
�. S — 5 Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: r 7 /0 Inspection #2:
Location: 1057 144th Avenue New Richmond, WI 54017 (NW 1/4 SE 1/4 20 T30N R18W) Waldroff Meadows Lot 9 Parcel No: 20.30.18.1050
1.) Alt BM Description = Pafi9
2.) Bldg sewer length
- amount of cover
Plan revision Required? Yes KNO oz,
Use other side for additional information. �,
Date
SBD -6710 (R.3/97) Ins tors ignature Cert. No.
`
Safety and Buildings Division County
® pi sconssn N 201 W, Washington Ave., P.O. Box 7162 Madison, 07-71 Sanitary Permit Number (to be filled in by Co.)
De artment of Commerce (60 266 -R s30 �3
D
Plan I..
Sanitary Permit Applica ion , , to . Number um
In accord with Cotton $3.21, Wis. Adm. Code, personal info don VA4e
may be used for secondary purposes Privacy Law, s 5.04(1)(m) �'' �(]G1¢ / Project Address (if, afferent than mailing address)
I. Application Information - Please Print All Information ZU Cb�N / / ' i " t e .
NG OFFI
Property Owner's Na I OG ` / • Parcel k Lot k 9 Block N
Pro Owner's M ailing Ad ess Pro
Pem' g Pe __
I :
Z::�� v' 'A �A , Section _
City, S to 7Ip Code j Phone Number
!._ (circle 0DO o ��
T N; R E o
I T
I . ype of Building (check all that apply)
Subdivision Name CSM- Number
J44 or 2 Family Dwelling - Number of Bedrooms f l
❑ Public /Commercial - Describe Use
I-1 State Owned - Describe Use D /ST C&ZL W - ❑City _ ❑V' �ge Township of
III. Type of Permit: (Check only one box on line A. Coinplete line B if applicable)
New System ❑ Replacement System ❑ Trea ent/Holding Tank Replacement Only ❑ Other Modification to Existing System
` List Provtous Permit Number aMDate Issued -
n, ❑ Permit Renewal ❑ Permit Revision ❑ C hange of ❑ Permit Transfer to New
Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all that apply)
Non - Pressurized In- Ground ❑ Mound > 24 in. of suitablel 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
1 Re circulating Synthetic Media Filter yLlachin Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V._Dispe Area Info ation: /Q — L
I�csir Flnw (gpd) Design Soil Application Rate( so I Di persal Area Required (sty Dispersal Area Proposed 00 System Elevation
Vl, "T "ank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units k /2- U Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Aerohic Treatment Unit
i
nosing Chamber
VI R espo sibility Statement- 1, the undersigned, a tme r sponsibility for installation of the POWTS shown on the attached plans.
Plum •r' a e ( iin0 Plumbe s Si 26fu MP /MPRS Number Business Phone Number
PI un is Addre ss (Street, City S te, Z16 C )
Viii ount /Dc artment Use On)
Approved ❑ Disapproved Sanitary ermit Fee (includes Groundwater Datp Issued Issuing Agen Sigilatur Stamps)
Surcharges Fee) Q�
Owner Given Reason for Denial '/ 26D 3151
IX i BtlTd1I1%&fdt*l*roval /Reasons for Disap ain val
,
( S P.;L c_ tank effluent filter and �� D.SZ W 15 dispersal cell must all be serviced /main ,��
as per managemen pan rovi1 y p u dL Dw
2. All setback requirements mus a maintained �S�Zrt�z�
per applicable code /ordinances. i X 4
�'� 3•
s a�
Attach complete plans (to the Count only) for he syst on pope not less than 8111U 11 Inches In size
SRD -6398 (R. 01/03)
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CONTOOR ELEVATION RI•z0, 73.20, YS•d 0 47.20 U.
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Wsc6nsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code Cou�y .
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must '
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale ordimensions, north arrow, and location and distance to nearest road. 02 & - j j > 2
— q l) oq�>
te
Please print all information. Da_
Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). (� 7
Property Owner Prey Locator
Govt. Lot ,V 1/4 1/4 S} T N R E (or)
Property Owner's Mailing Address Lot _# Block # Subd. Name or CSW
g Q% 9
Number Village Town Nearest Road
icy State Zip Code Phone city ❑ �
t ) c hnAord i G . Qd- A
[5P New Construkfion Use: 0 Residential / Ntmhber of bedrooms _ 3 _ y Code derived design flow rate 0 O
❑ Replacement ❑ Public or commercial - Describe: �
Parent material 5 h `5� ka cc Pla' elevation if ble ft.
General comments S ys4 m o t -9 J , -7b p q Z, 7C Zo w R r '?U 7 o
and recommendations: AL4 • ;e he- V, '10,P 8 �(, �� Z--0 U" e r ' 1�
O x D 2.
1-4 1"c�� lsi S levy rr0 2r �rr)Z (cl -- ��6d
Boring COUNTY f ST CRUIA
1 17 1 Boring:# ® Pit Ground surfaceelev. � Q ft Depth to limiting factor in Z Soh Fr lC
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary l :Gott G
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. --*E - 3 'Eff#2
I z Sil 2rrxAhk ncA c: I op .• 1 5 .9
Z l ow- 0i Si 1 r» -Pr C5 S. S
3 21e-i lO �I{lo g m ! "_ - 17
Boring # ❑ Boris
❑ Pit Ground surfaceelev. Qb.� ft Depth to limiting factor I09 in. F?-- r-07#1 Application Ra�
Horizon Depth Dominant Color Redox Description Texture .. Structure Consistence Boundary Roots GPD/ftn
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `EfW
. p
_ - —
- t. 2
Effluent #1 = BOD > 30 220 mg& and TSS >30 150 mg& ' Effluent #2 = WD < 30 mg& and TSS < 30 mg&
CST Nam (Please Print) Signature CST Number
2533oq
Address Dave Evaluation Condudad Telephone Number
2 -22 C", -z0 -C)c 10241 -(A
owner ! C l� �a —�-� Page Z of 3
Prope Parcel ID #
F # ❑ Boring
® Pit Ground surface elev. 9 3 e ft. Depth to limiting factor (o� in. Sol A Rate
Horizon Depth Dominant Color Redox Description Texture Strudum Consistence Boundary Roots GPD
in. Munsell Qu. Sz. Cont. color Gr. Sz. Sh. i 'Eff#1 *Eff#2
1 — S' 2 45 v-E
Z 5-4 b vrAk — Sil 2rrao "-'Vr C
3 to I U m s 65Q
Bor # ❑ Bormg 11
. 20 to lim' ' fa in.
Ground surface elev. ft. �g —�
D F6] pit � Sol Applicat Rate
Horizon Depth Dominant color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i "Eff#1 - 01#2
1
6 -4 10 2 SO I 2mobk c Ivy 5 •8
Z 1 1 -zo IOVr4 4 Si I 2rm mrPir SS I —
3 mS MI 1
n Boring BOcr'g # Q pit Ground surface elan. . ZD 8. Depth to limiting _ in. F -51
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Shudure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 4 10 2 5'I .
2 �4 -SIC !0 •I 2mabk r4 r c
3 Q -Up y! rns O - �• Z
Effluent #1 = BOD, > 30 220 mg& and TSS >30 150 mglL ` Effluent #2 = BAD, a 30 mglL and TSS _5 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3151 or TtY 608- 264 -8777.
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PAGE_ 3,OF�
NAME L r�ra -���c LOT# q LEGAL DESCRiPTIONNk) /4S[ l4,SZOT30 ,N,R lrf E (or)
SCALE: 1 "= Cho
BM 1 ELEVATION =.n
BM 1 DESCRIPTION fl p 1 „ F. e r
BM 2 ELEVATION
n
BM 2 DESCRIPTION :4 R .t J= '
SYSTEM ELEVATION P Q2 � qw e� qa „�..
+1910 "W t e
ALTERNATE ELEVATION 8�' 70
CONTOUR ELEVATION 9J•Zo, g3.2o, 4S. ?a �� g7.ZC7
` �M� Casa
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pf:,w r�r
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SIGNATURE DATE
// - o C)
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Bu yer _ ,S
Mailing .',Address
Property Address
CSS e j/ ti; i
(Verification re uired from Planning Department for new construction)
Cit -/Stare
} Parcel Identification Number 0A6-11
LEGAL DES CRIPTION
Property Location A[ '/, Sec. c7Q , T__jQ N -R ff W, Town of f ?'eA)►'ar,el
Subdivision I old" 4 Lot #
Certified Survey Njap # , Volume , Page #
Warranty Deed # 7 ay] , Volume Q3 `' , Page #
Spec house ❑yes X no Lot lines identifiable N yes O no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumpin4 out the septic tank every three years or sooner if needed by a licensed pumper. What you put into the system
can affect the (Unction 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 wastewatcrdisposal 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.
S GNATUU QF APP1., .ANT 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 owners) of
; ,GN � ,T,P, prop Ty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
) OF APPLIC T A l 0
DATE
* * * * ** Any infonnation that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
*s « **s
t
** 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
t
J 239 2 P `I 5 9 - 7 aZ3 E! �4-
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
This Deed, made between David J. Waldroff and Julie A. RECEIVED FOR RECORD
Waldroff , husband and wife 08/01/2003 09:20AN
Grantor, and Scott M Conway Grantee. WARRANTY DEED
Grantor, for a valuable consideration, conveys and warrants to Grantee EXEPPT #
the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00
(if more space is needed, please attach addendum): TRANS FEE: 174.00
Lot 9, Plat of Waldroff Meadows in the Town of Richmond, St. Croix COPY FEE:
County, Wisconsin. CC FEE:
PAGES: 1
Recording Area
Name and Return Address
First National Bank of New Richmond
PO Box 89
New Richmond, WI 54017
026- 1143 -90 -000
Parcel Identification Number (PIN)
This is not homestead property
(is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of July 2003
0 9 1 AAOUO . �
* vid J. Waldroff
* * ulie A. Waldroff
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) David J. Waldro and Julie A. Waldroff, husband STATE OF — — --- -- __ -- , )
and wife ) ss.
-- - - -- – _ County )
authenticated this day of July 2003
Personally came before me this day of
the above named
* Kristin Ogland -- ----- - - - - -- – - - - - -- –
TITLE: MEMBER STATE BAR OF WISCONSIN _— ---- - - - - -- --
(If not, _ to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY _-- --
Attorney Kristina Ogland * --
Hudson, WI 54016 Notary Public, State of
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
* Names of persons signing in any capacity must be typed or printed below their signature. Informa�ion Professionals Co., Fond 0- Lac, 2 I
800- 655 -2021
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1999
• - POWTS OWNER'S MANUAL & MANAGEMENT PLAN page _Z., of
FILE INFORMATION C SYSTEM SPECIFICATIONS
Owner ��' / Septic Tank Capacity a l O NA
Permit A ®� Septic Tank Manufacturer s G NA
DESIGN PARAMETERS Effluent Filter Manufacturer G NA
Number of Bedrooms D NA Effluent Filter Model _ A9 ❑ NA
Number of Public Facility Units ,E�NA Pump Tank Capacity al ANA
Estimated flow (average) g al/day Pump Tank Manufacturer ANA
Design flow (peak), (Estimated x 1.5) g al /day Pump Manufacturer ,®
Soil Application Rate gal/day/ft' Pump Model O-NA
Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ANA
Fats, Oil & Grease (FOG) 530 mg /L O Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L O NA D Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L D Disinfection O Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) C NA
Biochemical Oxygen Demand (600 530 mg /L ;f�In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade D Mound
Fecal Coliform (geometric mean) 510` cfu /100m1 D Drip - Line ❑ Other:
Maximum Effluent Particle Size Y in dia, DNA Other: O N A
Other: DNA Other: - 1 NA
* Values typical for domestic wastewater and septic tank effluent. Other: J NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: months) " (Maximum 3 years) ❑ NA
earls) ;
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y,) of tank volume 0 NA.
Inspect dispersal cell(s) At least once ever ❑ months) (Maximum 3 ears) El NA
P Y years) y
Clean effluent filter At least once every: D, month(s) ❑ N�.
earls)
Inspect pump, pump controls & alarm At least once every: D month(3) D NA
D earls)
Flush laterals and pressure test At least once every: D month($) O NA
❑ year(s)
Other: At least once every: ❑ month(s) ❑ NA
O year(s)
Other: O NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewur; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator, Tank
inspections must include a visual inspection of the tanks to identify an missing or broken hardware, identify any cracks or
P O Y Y 9 Y
II �
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface,
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires tho
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y,) or more 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.
All other services, Including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmvnt
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
Patti
START UP AND OPERATION
For new construction, prior to use of the POWTS chock treatment tank(s) for the presence of painting products or other cnvmica
that may impede the treatment process and /or darrtat7e the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage 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 may 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 cell(s) and may result in the backup or surface dischalue of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contruis t(,
restore normal levels within the pump tank.
a I ells, Do not drive or ark over, or otherwise disturb or compact, thu areL'
Do not dove or park vehicles over tanks and dispersal c p -
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
f )undation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medication- oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the systern is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings Sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
I A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems roust
comply with the rules in effect at that time.
❑ A suitable replacement area Is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
O The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at thco
infiltrative surface. Reconstructions of such systems must comply with the rules In effect st, at time.
r.. ,
4.
< < WARNING > >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS _
re
POWTS INSTALL POWTS MAINTAINER
Name ? Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATO Y AUTHORITY
Name Name
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.640), (2) & (3), Wisconsin AdminigUstive Code.
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