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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES t
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PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Q/ Internal Use Only PERMIT #.�"�y =100
U LVI ' Repair Permit issued in last 5 years U Not in Watershed
❑ [3� Repair within Boyd's Comers, W. Branch or Croton Falls Res. El Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland f3 Joint Review
SITE LOCATION - s/ /io re-
OWNER'S WN !d l ������ . TM # ��
NAME n:L 4fele -1 PHONE #q 14 ,),6 1--, � 0
MAILING ADDRESS C G��r► f__
APPLICANT
! ame & Relatibnship p.e., owr)dr, tenant, contractor) '
DATE /% 2— FACILITY TYPE �s PCHD COMPLAINT #
PROPOSED INSTALLER edL 1 nd-lltl PHONE # 1701— (' b -T.. %
ADDRESS i U rte✓' REGISTRATION /LICENSE #�C�S_t�%
Pro sal (Include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
Di1 el Y-0
I, as owner,agree to the conditions stated on this form
h
SIGNATURE --` TITLE DATE 3 t( �tz
(owner)
I, the septic installer, agree to comply with the conditions of this permit for the septic system repair
SIGNATURE TITLE DATE Z-
Qnstaller)
ProRml emproved with the foll 06L.iflons:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best ft design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
l:I 14 �I ►_14r1zL-t•1,1I1
Proposal Approved Proposal Denied ❑
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inspector's ignature & itle D to Ekpirfition Date
.Repair proposal is in compliance with applicable codes Yes 0 No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
Environmental
Protection New York City Department of Environmental
Protection
SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR
DETERMINATION
Pursuant to the authority granted under:
Article 11 of the New York State Public Health Law; Rules and Regulations For The
Protection From Contamination, Degradation and Pollution Of The New York City Water
Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 NYCRR
Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems;
Putnam County Septic Repair Program Plan - March 2005.
DEP Project# • 71314 PCHD Repair# A^ 0V J__ /2-
Site Location:311z 4-k4J101ve % --. Ff. Av rOk T.M.#
Vj:'73 --(-A5
Reason for ,point Review:
Drainage Basin 200' of WC/Wetland _ Repeat Repair in 5 Yrs.
Name of Owner: Pg�- #e_ -P J _
Owner's Address: W G6oW e .
Drainage Basin of Project Site:
Installer: �4d �Y /4 4 (i
General Description of Sewage System Repair: fXJA /r ( 3)
Dates of Site Inspections and Soils Tests: _ lell -L
Approved 8/ *Incomplete Delegated * *Denied
*Required: Soils Tests Repair Sketch WC/Wetlands Wells Other.
"'`Reason
Determination made by:
Engineering Division Date
Putnam County Department of Health
Division of Environmental Health Services
SSTS Repair - Final Site Inspection
Date: 3 �- ' Inspected b /
�P Y� Installer: _1v'►ra'ck //
Street cation: -V._ l ie 5"m fir. Owner &&te
Town: 7P�e fAI&I Repair Permit #: 'TL- o �f S - /.Z TM # 2 S, 7A
Additional Comments: Cew�C ay-}m c- 4,0 A
RFSI Rev- 011312
1. Type of System: Conventional 0 Alternate Comments:
2. Se ti Tank
Yes
No
N/A
Comments
a. Septic tank size 1,00 1,250... other .....
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d. Distribution Bog
i. All outlets at same elevation (water tested) .. .
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
trenches
rv-
e. Junction Bog - �io erl set .......:..... ...............
f. Trenches
i. S stern �ompletely opened for inspection
ii. Length required 36 Length installed
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iii. Pie slope checked ....................... :..........
iv. Installed according to plan .....................
V. 10 ft. from property line - 20 ft - foundations ...
vi. Size of grav '/< 1 diameter clean .........
vii. Depth of gravel in trench 12" minimum .........
vui. Ends capped .... ...............................
ol
g. Pump or Dosed Systems
3. Sewa e System Area
a. SSTS Area located as per approved plans
b. Fill section -
c. Distance from water course /wetlands too
4. Overall Workmanship
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
eVue y
c. Backfill material contains stones <4" diameter ...... ....
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments: Cew�C ay-}m c- 4,0 A
RFSI Rev- 011312
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PUT'NAM COLNTY DEPARTAMNT OF. HEALTH.
H•
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL M. IVIDUAL/C01SBIERCUL SITE INSPECTION FORM.
SECTION A.' GENERAL INFORMATION
1� ,/ ;
Name of Project �� P_ _ �(� :�. � w.r o • County; � 1/,�� '
Site Location
Building construction begun ,Extent.
Is'property within NYC WatersheV.... ......... ...... Y.es " F7.140
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 'Hilly ❑Rolling Steep slope Q entle slope Flat,
2. vidence of.wetlands a Low area subject to flooding [�odies of water.
�rainage ditch-s ❑ Rock, outcrops
3... Property lines or corners evident ......... :.: ............................................ ❑ yes ® No
4... 'Do water courses exist on or adjoin-the- property. s No
5. Will these affect the design of the sewage system facilities?
6; Do watershed regulations apply in this development ?..........
7. Will extensive grading be necessary ?... .....................
8: Will. extensive fill be necessary. for SST .S ? ...........................
9. Do -filled areas exist within the SSTS'% area ? .........................:
L� Yes: lv'o
Z.Yes F7. No
Yes ff No
—❑ Yes t""No'
❑ Yes . No
If yes, what is. the condition of the fill'?
SECTION C. SOIL OBSERVATIONS
10. Appearance of soil: ID's, Gravel oam lay Hardpan Mixture .
❑ � ❑
1 L._...�)bseraed�irom: __....._ 3orings ❑ Bunk- cut....__:_ .__ - .:Backhoe
Lb?12. Soil' borings /excavations observed by i.,f� o- r�`� ---" on 3
.13. Depth'to groundwater y.� on
14. Depth to mottling on
16. Are test holes representative of primary & reserve areas ...... .......... ... .................... Yes No
16...Soil percolation tests made by on
17. Soil percolation" tests witnessed by on
SECTION D (on back)
Form ST•1
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SECTI ®ND. DI2A.YI AGE_
18. Will proposed grading materially alter the natural drainage in this or adjaceat areas? Yes �No
19. Will groundwater or surface drainage require special consideration? ..... `Q.Yes E
20.• Will gullies, ditches, etc:, be filled and watercourses be relocated ? .................. ..... .Yes o
SECTION E. REMARKS "
21. If a common water supply is proposed; has aninspection beeFn made of the
existing or proposed source and facilities ? ..:.....:...... .... Yes; Q No
Inspection data
22. Do adjacent wells and/or sewage systems' exist? ................ .......: :::............ ® Yes, a :_ N
o
23. Additional comments -
24. Site observer /inspector an4 title
25. Date(s)-of pbservafion(s)inspection(s)
TEST PIT PROFILES
Hole r �� - -Lot %Tole 4 Lot 0 Hole � Lot r
Depth to water Depth to water - Depth to water -
Depth to motthq Depth to mottling Depth to mottling
Depth to rockr=p. - j Depth to rock/'=p. Depth to rock/imp.
G.L. �i I w � •��� .� fi i I G.L;. G.L. • .. .... .. .
0.5 _ . 0.5 0.5
2.0 WP�� COrx /c s c. , 2.0 10
3.0 Jo&1" ` i,; �, Y Ne- c 3.0 3.0
4.0 Sflh en��t1 4.0 4.0
5.0 5.0 5.0
.6.0 6.0 6.0.,
7.0 7.0 7.0
8.0 8.0 8.0
9.0 9.0 9.0
10.0 10.0 10.0
PUTNANI COUNTY DEPARTI IENT OF HEALTH
DIVISION OF EINVIROMT IENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TR:EATIMENI T SYSTEM
Owner: Address
Located at (street): , �1Z �.��s� Or 1. P �-� TIN[ 4 Section: _ Block _ Lot
Municipality: ec hu'-'7b" Watershed: E-��? �-- r'� -�•G�
SOIL PERCOLATION TEST DATA
Witnessed by: erl.J
Date of Pre - soaking: Date of Percolation Test: /Z
Hole No.
Run No.
Time
Start —
Stop
Elapse
Time
(min,)
Depth to
water from
Found
surface
(inches.)
Start - Stop
Water
level drop
in inches
Percolation
Rate
ruin /inch
1
26 V -3 N
.30.
IS-199
2
d
3
-I. XZ_
E
4
5
t
2
3
4
1
2
3
4
5
2
3
4
5
Notes:
1. Tests to be repeared at same depth until approximately equal percolation rates are
obtained at each percolation test hole. (i.e., < 1 min for 1-30 min/inch, < 2 min for 31-60 min/inch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Forth DD -97• go t of
3 r��
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Feb 08 04 10:09a Tyndall
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner- of Health
(845) 279 -5989 p•1
ROBERT J. BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York: 10509
REQUEST FOR MLD TESTING
ROBERT MORRIS, PE
Director of Environmental Health
All information below must be fully completed prior to any scheduling. DATE: j 12—
ENGINEER OR FIRM: k&rJ_,,(�PE1ONE #:_2.1.y'S Zi
PERSON TO CONTACT: GLYZ`
❑ NEW CONSTRUCTION ❑ REPAXMIPROGRAM ❑ ADDITION PROGRAM
REASON: DEEPS: !,B' PERCS: R PUMP TEST: ❑
ROAD /STREET:_q
TOWN: %�T� -I,L► ETC' -L'�- 1710 i i ion L9-k
_ TAX MAX' #:
LOT #:
NYCDEP CRITERIA. FOR JOINT REVrEW AND WITNESSING OF SOIL TESTING
YES -NO
p ❑ Proposed SSTS within the drainage basin of West Branch or Boyds Corner &
Croton Fails Reservoirs.
❑ ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
❑ ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ ❑ Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
❑ ❑ Proposed SSTS for a Commercial Project
It is the responsibility of the design professional to provide the above information prior to soil testing. The
Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you
answered 1,es to any of the questions, NYCDEP must witness the soil tests. .This Department will coordinate a
mutu ally suitable time for field testing with the Design Professional and NYCDEP.
If a project . has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the
design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR COUNTY USE ONLY
DATE: Tom=
COMMENT'S:
REQ. FOR RF1D TEST MKLY
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278-6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278-6085
Early Interveafionftesaool (845) 278-6014 Fax(845)278-6648
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REBECCA WITTENBERG, RN, BSN
Public Health Director
ROBERT MORRIS, PE
Director of Environmental Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW
ATTN:Da4--s
FROM: esz'- � S —�:)
PRIORITY - SEPTIC REPAIR
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
JOINT REVIEW
PROJECT: �e'A
LOCATION: 3 y� J, K e.n re r- ,
TOWN: _eC4" el. }E)n TM # ,R5r,. i3 %-21
NOTICE OF COMPLETE APPLICATION: DATE: 3 % /Z
❑ Within the drainage basins of West Branch, Boyds Corner, or Croton Falls
R oirs
ithin 500 feet of a reservoir, reservoir stem or control lake.
❑ Within 200 feet of a watercourse or a DEC wetland and appearing on a
subdivision map approved after December 31, 1992
❑ Design flow greater than 1,000 gallons /day.
❑ Commercial SSTS.
SEPTIC REPAIR JOINT REVIEW
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT..SYSTEM..REPAIR.�,
YES NQ Internal Use Only PERMIT # �r
F�
U 'k���f Repair Permit issued in last 5 years I Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated --- 7h- Naf
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 3 y 2 U-1c -- ,share D1f OW N TM #��'13 =���
OWNER'S NAME ! - - -D_ . �-� -- PHONE # 9 /jr 6/-- P? 90
MAILING ADDRESS �e�42 erA ore, 2r, h E3reurs�ek � ,o rb y
APPLICANT C&W -L:
Name & R61ationship Ole., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER I'"�I,t �1, PHONE # W ,
ADDRESS -'10 -fVV W1 &&Aw r� REGISTRATION /LICENSE # 3 061-0
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal.from licensed professional depending on the
nature and extent of the repair.
a � /G,.•9. 'Ji l.� � �� � 14 !AI)�� I r�rii� c'1!', � /.>>w /'A17/IC.%�.%9L!. tSy�G I!
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I, as owner,agree. to the conditions stated on this form
SIGNATURE TITLE pc a IV 0- DATE
(owner)
-I;.the-septic_insxal).era agree to comply with the conditions ofthis permit for the septic system repair
SIGNATURE TITLE DATE Aaq
(installer)
Proposal apRroved with the f in conditions: ,
1. Procurement of any Town Permit,if applicable.
Submission of as built repair sketch by the'septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Denied
& Title
is in comDliance with aoDlicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
to jD 0,-1
Date
Yes
30 !o
Ex iration Date
O No
Rev. 2/07
Oct 28 09 10:40a Tyndall (845) 279-5989 p.2
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SH,ERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI; RN,-MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
ROBE RT- YORRIS;•PE* —
Director of Environmental Health
ADDITION APPLICATION RESIDENTIA14 V
LV
STREET ��C �tl'OWN TAX MAP# .S"
NAME ✓ . PHONE 714) f-a l - 1 X10 PCHD '
MAILING
ADDRESS
%p
DESCRIPTION OF
ADDITION_ A•]lv.d OE Pi P i 6,w4., N6W t : i�dyl2 A-DA noN
NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS �.
(FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR)
"Any addition which is considered a bedroom requires formal approval of plans (Construction permit)
prepared by a Professional Engineer or Registered Architect in accordance with'applicable sections of the
Putnam County Sanitary Code.
Please submit this form and the following to Putnam County Health Dept.,1 Geneva Rd,
Brewster, NY 10509, Phone: (845) 278 - 61.30.
1. Certified check or money order for $100.00.
Sketches of existing floor plan (drawn to scale, all .living area including basement)
✓3. Two sets of proposed floor plan drawn to scale — with name, street and tax ma #
P ( p )
*Non- professional sketches are acceptable
4. Copy of survey showing well and septic locations to the best of your knowledge.
Include date of installation if known. Label all wells and septic systems within 200 feet
of the property line. Contact this office with any questions. .
5". Copy of Certificate of Occupancy from Town or Certification from Building
Dept. with legal bedroom count of dwelling.
OFFICE USE
COMMENTS
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
SHERMLITA AMLER, MD, MS, EAAP
Commissioner of Health
MLORE'I" I'A MOI.INARI, RN, MSN
Associate Commissioner of Health
Patrick Hefele
9 Tanager Road
Brewster, NY 10509
Dear Mr. Hefele: .
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
June 20, 2007
Re: Addition — Approval — A- 123 -07
No Increases in Number of Bedrooms
342 Lakeshore Drive
(T) Patterson, TM # 25.73 -1 -29
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
I have received and reviewed the plans for the proposed addition to the above mentioned
residence. The proposal for the addition has been approved as per plans bearing the approval
stamp from the Department dated June 19, 2007. The addition is approved with the following
conditions:
1. The septic system area must be roped off as to not allow construction equipment on
any component of the septic system.
2. The total number of bedrooms must remain at .two without prior approval by this
Department.
3. The area of the existing sewage disposal system, and its expansion area, must be
maintained.
4. All plumbing fixtures must be updated with water saving devices, i.e., new- low flush
toilets; 'restrictors for shower heads and faucets; etc.
5. This Department recommends you contact your local Building Department to ensure
setbacks and other current codes can be met.
6. The approval is for the proposed changes only. This approval does not validate any
construction shown as existing that has not obtained proper approvals.
Any permits or variances required are the responsibility of the applicant and the jurisdiction of
the Town of Patterson .
If you have any questions, please contact me at (845) 278 -6130, ext. 2261.
Sincerely,
Gene D. Reed
Senior Environmental Engineering Aide
GDR: ens
cc: BI (T) Patterson
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
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_........- .POTNAM - COUNTY-DEPARTMEW OF HEAtTH _..__........------ ....._.,.._ r..__________. .__. ......
,__.,_.:__..- .- .-- ___,.� ....__� .. - ___. -._ ._._. �_ _ ------- '- •---- ' -••_.
HOUSE- L-ANS-AP ROVED FOR BEDROOM
T,r'i•# �S, 7 3 -- I— 2 i
4lL SU SEQUENT- REVISION /ALTERATiONS-TO THESE- HOUSE ----- _ _._._.___._.__..._T_..____._... __- .- •___._._...__._..____..___ty ..._ ___ ___._._
'LANS UST BE SUBMITTED TO THE PCDOH FOR APPROVAL
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iIGNATURf & TITL DATE_
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SIGNATURE & TITLE DAT . .
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SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Town Leaal Bedroom Count
ROBERT J. BONDI
County Executive. _ ...
Re: (Owner's Name)
Tax Map #:�.
Address: �� v ���..
Town:��,,.�
Year Built:
According to records maintained by the Town, the above noted dwelling,
is in compliance with Town Code.
is not in compliance with Town Code.
The Legal Bedroom Count is: a
This information has been obtained from:
Certificate of Occupancy:
Other:
Building ector Date
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services.(845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool(845)278 -6014 Fax(845)278 -6648
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