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-c�T _ nT�u�':;cur� °rxut:rtur cuit�riaa>: vc�r'u�s�wau�.lii,rusai,xsY�rrm . ^ , ::/ H`7 /�S O/7 '_' ° .
ij / J Ta= Map Co
TBlocicr v�_
t iln Iicanf;Name ;" . r Formerly ` Subdivision Name
�Pp
S v Lof M �J
MaWng Address Date Permk Iesned
�� }
7
System id by Address S
Separate.Sewets16e _
Consisting of : , Gabon. septic Tank and -- i.�,...
Wates Supply: - PA l Snpplyr Fa om '- Address
-.
... ,✓
or: Private Sapply;DriDed;b ` y ' Address
fa
CS'��so�'I ,
Balldbtg'Type� Has Erosion Control Been CompletedY
;
...
Nambek of Bedrooms ` Has Garbage Grinder Boon InstalledY
77 77
'`Atber Regolremonts '
I certify that th'e syatem(s) as dieted serving tfie above. promises were constructed essentially ^as �howntoii e
a of the completed work ( copies
;.
of which are attached) and in accordance" with the standards rules and requlatlo in ccordan with
a plan and the permit issued by the
Putnam Co y pa Of
De rtment Health
Certified Y
Oats _
Address
a
lung No
Any person occupying premises saivetl by the above system s shill ionmptly take such action's may be nsKesyry to sacun tM cot raction of any unsanitary.
;.conditions resulting from weh usige ADDrowl of the separ+te swvecaps System shill become nu It end void;af soon ei a pubtb fanitaFy awy becomit.
lIll avatlawi7ind the-, pprov l`-of the -- prly +te witer supply sh+ll:become;,null an`d:�void whin .public uvula "iupply, bieomes avillatiN Sueh aaprovalc a :
wbiect ;to odific+tion pr change whfih An the tudgmenP of the Commissipner of Healt uch revoeatbn,.•modifieation or, enan4e , ls,- necessary.
r ;
��
Date Br
Titlo
M
WELL COMPLETION REPORT Office ,Use On'
DEPARTMENT OF HEALTH
Division Of 'Environmental�Hea1>I Iq S`ervices C
PUTN�.M COUNTY DEPARTMENT OF HEALTH
WELL LOCATION
STREETAOURESS' .,..,., ...o. _o..... ." .,..." ....
WELL OWNER
NAME: ADDRESS:
P81VATE
O PUBLIC
USE OF WELL
1 - primary
2 • secondary
RESIDENTIAL ❑ .PUBLIC SUPPLY ❑ AIR /COND./HEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM ❑ TESTIOBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT __S_. gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 6�O gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
` WELL DEPTH __2 ft•
STATIC WATER LEVEL � ft.
DATE MEASURED Sly
DRILLING
EQUIPMENT
❑ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH ft.
MATERIALS: STEEL O PLASTIC O OTHER
LENGTH.BELOV/ GRADE
JOINTS: O WELDED YTHREADED O OTHER
DIAMETER 7 in.
SEAL: O CEMENT GROUT d6BENTONITE OOTHER
WEIGHT PER FOOT lb./ft.
I DRIVE SHOE 9YES ❑ NO LINER: OYES iYNO
SCREEN
-DETAILS -
DI;
'SLOT SIZE
LENGTH (ft)
DEPTH 70 SCREEN (ft)
DEVELOPED?
FIRST
!METER(Iin)]
_. --
..
. O YES - O -M
HOURS
....:..._.
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE;
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH tt.
WELL YIELD TEST If detailed pumping
'
M,V HOD: O PUMPED I tests were done is it
(F COMPRESSED AIR ;formation attached?
❑ BAILED ❑ OTHER ; O YES C3 NO
WELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
"9
We11
Oia-
Inter
FORMATION DESCRIPTION
tOOE.
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft..
YIELD
gpm-
Land
Surface
O
3
06
4
��
�,'
3d6
/
WATER WCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? DYES ❑ NO
ANALYSIS ATTACHED? O YES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE1�•��'►C r` sJ,61 e _CAPACITY 7 - !b
MAKER G- n ny_ DE17H 000
MODEL SPA. -12 VOLTAGE. H�
L DRILLER NAME DATE •/,
�ERT M. HYATT & SONS, INC. �7
ADDRESS Well Drilling SIGr7ATURE
Rte-II R.R. YORK 12563 A
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-76 e47
Owner or purchaser4bf Building Section Block Lot
Building Constructed by
Alf
LocAjon - Street Subdivision. Name
FA�7q Xr-5 A/ 2-��
Municipality SubdivisionLot #.
lt4 u. y ,
Building Type
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
.worrepresent that aR61= wholly and completely responsible for the location,
ship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by 'which fails to
operate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by A& to such - systen, except where the failure to operate -properly is
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environirental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the b 'lding u lining
the system.
n i
1�
r�
Dated this C3 . day
1
Ge era Contractor (Owner) - Signature
Corporation Name (if .)
m , ,,,. i�
s
rev. 9/85
mk
Title
vivo —
"D
Lf �CoorrpZY
.r
3, 0 , 1�
.c.
LAB d --
Yorktown Medical Laboratory, Inc. Time
: �"
321 Keu Street _
Date Taken: 3
Yorktown Heighis, N.Y. 10598 Dst e` -R c" d : �-
(914)245.3203 Date Reported:
Collected By: u P�pR� ----
Director: Albert H. Pado van i M. T. (A SCP) Referred By
Sample Location: Acl,C,4
COLONIAL RIDGE X;SOCIATION, INC.-- i SSeAMP - -X T ��
495 MAIN STREET
ARMONK, NEW YORK-1.0504 ?hone a ?ji —s22s ,' S a m p l e ^• -I. J e
Phone I .
J Repeat Test? — (check one)
L
ON THE QUALITY OF
Ac
- d -tI -
C:,, o -_de
_ :etergerts, MBAS
_ .- -tress, Total
_ ';--'.roger, A_.:-o., is
_ :_:roger, trate
Tota.1
Sulfate
S_' -de
3 u I _te
CO -. Ter
Lead
Manganese
Sodium
Zinc
`dISC TA:t OUS
_ pH (units)
_ Color (units)
_ Odor (TON)
Turbidity (N TU )
VTCRO?" I031CAL (CFU /100 ^L)
GENERAL BACTERIA
Standard ?late Count
(C ?'J/1.OraL)
"SEC
Total Coliform
Fecal Coliform
Fecal Streptococcus
ii05m ? ?OBABL .iL'.'•`3:.R TEE •- 'rL
Total Coliform Index
Fecal Col,-form, Index
BEY FOR TERI-41NDLOGY
it /A = `tot Applicable
LT = Less Than (< )
GT = Greater Than ( i)
TNTC= Too Numerous To Count
CON = Confluent (= TINTC)
NR = :ton - reactive
REMARKS/ COY`4ENI'S (For Lab Use)
:ion - potable -
_
Other
-ple Status.
eac• )
n• _o.
3
504
5203
ct�er.
=0 ^_1:
LE
40C
_
T
40C
off
LE 2
GE 9.
p
GE 12
_
Other.
THESE RESULTS INDICATE THAT THE WATER SAMP (WAS) (,WASN'T) (Pt /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO 'YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS �INLICATE THAT THE WATER SAMPLE ( DID) (DIDN'T)(NIA)MEET WATER
SATISFACTORY CHEMICAL QUALITY STANDARDS OF
CODES, FOR THE.P ;.RAMETERS TESTED, AT THE TIME OF COLLECTION.
2/86 (Rvsd7 /87 )RWE
a,._... u VeAnva,11. M.T. ASCP), Director
II.
IV.
V.
Ila
AWWH:NI 1I X ( •
FINAL SITE INSPECTION Date
;CATION° J T -f-' .� ,! petted by
� i .� OWNER � c�
# G' % G% # OR SUBDIVISION LOT #
1C
COMMENTS
SEWAGE DISPOSAL AREA
a. SDS area located as per approved plans
b.
Fill section - Date of placement
2:1 barrier. LGTH WIDTH AVG.DPTH
c..
Natural soil not stripped
d.
Stone, brush, etc., greater than 15' from SDS area.
e.
100 ft. from water course /wetlands
SEWAGE DISPOSAL SYSTEM
a. Septic tank size - 1,000
b.
Septic tank installed level
c..
10' minimum fran foundation
d.
No 90° bends, cleanout within 10 ft. of 450 bend
e.
DISTRIBUTION BOX
1. All outlets at same elevation - water test
2. Protected below frost
3. Minimum 2 ft. original soil between box an enches
f.
JUNCTION BOX — ro 1 set
g •
TRENCHES
1. Length required - / Length installed
_.
2. Distance to watercourse measured--' ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet fran property line - 20 feet - foundations
7. Depth of trench < 30 inches fran surface
8. Roan allowed for expansion, 50%
9. Size of gravel 3/4 - 1 ". diameter
10. Depth of ravel in trench 12" minimum
11. Pipe ends capped
h.
PUMP OR DOSE SYSTEMS
1. Size of pump chamber
2. Overflcw tank
3. Alarm, visual /audio
4. Pump easily accessible manhole to grade,
5. First box baffled
6. Cycle witnessed by Health Department
estimated flaw per cycle
HOUSE -
a. House located per approved plans.
b.
Number of bedrocns
�c
WELL
a.
Well located as per approved plans
b.
Distance fran SDS area measured ZA
=c ft.
C.
Casing 18" above grade.
d.
Surface drainage around well acce ptable. "
OVERALL WORKMASHIP
a. Boxes properly grouted
b.
All pipes partially backfilled
c.
All pipes flush with inside of -"
d.
Backfill material contains stones "_in diameter
e.
Curtain drain installed according to plan
f.
Curtain drain outfall protected & dir.to exist.watercours
g.
Footing drains discharge away fran SDS area
h.
Surface water rotection adequate
i.
Erross.on control rovlded on slopes greater than 15 %.
1C
PUTNAAY CUUNTY DEPARTMENT OF HEALTH " Provi nml
RP4V 3/t6 'Divlslon of Environmental Health Services Carmel N Y.1051? Engle ,r/A
eer to de Pe t q
F COMPLIANCE
on CERTiFI TE O
CONSTRUCTION PERMIT FOR SE GE DISPOSAL SYSTEM G
rV
,Located at � �1i ��1 �' "'T�k�_L�ts- Toe"vn or Village � „,
Sabdivislon Name�i,,�° Snbd Lot # �+ � Ta: Map � � Block � Lot
Owner /Applicant'Namea'�f�IZYil3i ;'^ a,).� ,.
Renewal ❑ Revision
- -� Date of Peevloas Approval '
M»�IT Aaarr�sa T
. �Y1Ron7� 1 D5'
Bnildbtg TyperG^ t✓ Lut Ares B �• Fill Sectloa Only Depth Votttme
Number of Bedrooms- Design Flow G /P /D® PCHD Notlflcatlon is Regalred,When FIII bt completed
t
Separete Sewerage System, to consist 0: f Gabon Septic Tank, an �J t
To be eonetracted by ... �� Address
W#*,Sappy Pdblle Supply From Aaareaa
or �Prlvate'Sappiy Dulled ddre'
Other_Regnirements
I represent that -I am wholly antl completely. responsible,for the design and location of the proposed system(s) 1) that the. separate.,sewage tliiposal,syitem
above tlescntied will be constructed as shown on the approvetl,.amentlment thereto and in•accordance with the standards rules ;an regu a ions o e u ham
County' Department of''NealtR 'and that.on completion thereof a "Corti irate of Construction Compliance'. sat�sfac ;cry to the Commissioner %of Health will
be submitted' to the Department; anc a wntten guarantee will be furniihed'the owner,'his successors, h' eirs or assigns`tiy, the bu�ldec,ahat said -6'64 or"'. ill
place 'in gootl operat;ng 'conddion any,, part of said sewage oisposal`.system duffing the period of•.two (2) yearslmme tely_4ollowing the date of the'.issu-
ance :ot the approval of the:Certificate.of Construction' Compliance of the,original system or any repairi thereto; t at th drilled well desci� bed above
will be4ocateCa sh
own o the ;appiovedplan andtAaf saldwell'will'De Installed
County Depart hi of alih
r/ -
Date Signeed_ C
Address
APPROVED FOR CONSTRUCTION This approval:expuessooai , year fi 'm the
re4ocab le for cause r maybe mended `o`r, Mod Mid when considered n esiar
requiies a n w" rmit. A ro d' -for disposal of• "domesticsanit or
' ,
Date BY
c!
y«oi a with the stun ds' lea and% a Ions of�the Putnam
PE R!'A._
ense N'
e issu unless construction of a building has`been undertaken' and is
�th', m mif H Ith Any change or alteratwm of construction
s, a we-_r P lY
A
Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
`APPLICATION- TO CONSTRUCT ".A WATER WELD " -'
PCHD PERMIT #__
WELL LOCATION
Street Address
"Atv;me
Town/Village/City Tax
1m, .[ -v
Grid Number
(.,— -- Z —7
WELL OWNER
Name IMalling
"SIDENTIAL
O BUSINESS
11 INDUSTRIAL
Address
G• 4 �
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
b INSTITUTIONAL 0 STAND -BY�
V.Private
O Public
D ABANDONED
0 OTHER (specify
O
USE OF WELL
1 - primary
2- secondary
AMOUNT OF USE
YIELD SOUGHT_�gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
EMEW SUPPLY []PROVIDE ADDITIONAL SUPPLY
OREPLACE EX STING SUPPLY ODEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
^
WELL TYPE j
DRILLED
DRIVEN
®DUG
®GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES LAN0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �3�►
Lot N . Z _;
WATER WELL CONTRACTOR: Name �j .� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES r/ NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE" TO PROPERTY` FROM NEAREST WATER -MAIN: *
LOCATION S ETCH & SOURCES OF CONTAMINATION PROVIDED ^�
ON REAR OF THIS APPLICATION �J �N S SHE
(date) (sign ure)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above -is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requir ments of the Putnam
County Health Department attached to this permit.
3. Submit a Well Comp etion Report on a form provi ed th Putna o my
Health Depart en
Date of Issue: 1219
Date of Expiration: 1g a it Issuing Official
Permit is Non - Transferrable White copy:.H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Ovmer
Orange copy: Well Driller
4
Division OF Lnv.ircnmcntal Sanitation
AFFIDAVU CDRPOP;+TE (11NER APPLICATION
rop .PERMIT S7CBMOTTED TO
COUN-Y PEA-1 111
9
I
S514 one r of XF a 411 t*h - In t'j,e mis 4 -, e r Of p p'L --, c, a lion for
— — — — — -- —CG — — — — — -- — — — — — — — — — — — — — — — — — — — — — —
- - - - - --- - - - - - - -
o-r c ----- -ation ancl-am r�.j-t�)crSzed
tl-,B�r I a7. an of.-,
a 7Z 01 C 0r
h a 0 J-. C, e s
-- — — — — — — — — — — — — — — — — — — —
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a nd
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-p e C, t -,es, all sub
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se,
n to. r,,,� 11his JQ �-y
e
lic
LINDA
R. BURI
Notary PubliC, State of New York
No.4808377
Qualified in Westchester county
commission Expiresmil�
'
Car-; rate Seel
APPENDIX B
p °tU,MM 4rrw 7I'Y DEPAFmoff�tn OF HEALTH - DIVISION OF ENVnROMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SET+1A3E DISPOSAL SYSTEMS
_..,,. _ ....- .....__.. �.;�•REVIEW�- SHEET-- .:CONSTRUCTION.PERI�ZT .,_... ....::. ...: . .:,..: ,.- .�- ,...:- ..� - -� . ��-_.:.�..-
DATE
BY: l 9 t
' (Street Location) /1 1— �-> (/I--
)OCUMENTS
Permit Application
corporate- Resolution
Plans - Three sets
Engine. -.rs Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
t mmmc of Own,--r)
s/s
SUBDIVISION
Perc 3
(3) Fill
ca
House Plans -Two sets
Well �/ /permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - VoluTe
D or J Box;Trench /Gallery; Pty pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder notes)
Design perc_ and deep results
Two-Foot Contours Existing &Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shcwn;gravity flow,suff. size
If pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains-Curtain, Leader, Footing
35'to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, - CARMEL, 'N. Y.' 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner G. Address /I (�,�� A�_) T_
Located at (Street "_% to , Block 1 Lot
kindicate neare8t cross s ree
Municipality. -- R�-���7 Watershed jgn-Z m,ti )
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water - �ia�er Level
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
5`
l
2
3
4
5
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE N0. HOLE N0.
G.L.J7 IL
I�
6" t
12"
18.. 1
24"
3011
36..
42"
48"
54" , I
6011,
6611. 1 /
7 8 if
84" ,I 've 67
INDICATE LEVEL AAA' WHICH GROUND WATER IS ENCOUNTERED .0q.T-j MAP
INDICATE LEVEL_ TO -WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED - -w o'�' Fk Lao NV�n
TESTS -MADE ;BY Z ;� _ . _ Date
� 8
Soil Rate Used !Z1- 3pMirVl "Drop: S.D. Usable Area Providedc)467- dpi[
No. of Bedrooms Septic Tank Capacity y"t7 Gals. Type
Absorption Area l'roded By 4&-1 L.F.x24" width.trenc ...
Adore s s 'ice K !% �3 JLHL
THIS SPACE FOR UrZ'IE BY HEA1frH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Date.
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JENNIFER LAME-
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COI.OellAl. Q10-JE ASSOC tATES -I"
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