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BOX 25
03134
PUTNAM COUNTY
ti
COWLLAN47E FO
Public So6o Rom
Water Suppip',
060r% bjentS
1. C y that a systii(d) 49 listed tserving,,tha, iki6vie prem4,1as were con�ti�icted'esseritially.eki-i?L a of the complete
prd
Putnam tme.nt di geelt�.
Date dart If 4il b
ubdivislon Nam
p We n. V., y unsanitary
st
�irson occupying premise sery
0ltJons4es4!tl6q from,_,_.-
Dot -Title 2
=
t�Or %. TA1, TTTATT
WL' LL lLUr1rLL 11U1V LNXXUal
DEPARTMENT OF HEALTH
'�� y: ii l'v ta.iJYl Ulm ally ii. lA .,Lai
�� 04 PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
-1 --
WELL LOCATION
STREcT ADDRESS: -FOWNIVILLAMCITY 710 NUMBER:
h R j C_ku" -d 0 r-� d o
WELL OWNER
NAME: ADDRESS:
c ��a.l .� (v u !! �: i c_ kct�s cl 4)r M.I&Ad it -C
@- PBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
❑ RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM 0 TEST/ OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT S__ gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION DADDITIONAL SUPPLY
ONEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL 3 0 ft.
IDATEMEASURED
DRILLING
EQUIPMENT
&MfARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED 0 -BqN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH_ ft
MATERIALS: FEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE
JOINTS: ❑ WELDED Q- THREADED O OTHER
DIAMETER 6 in.
SEAL: 94EMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT lb./ft.
DRIVE SHOE: ❑ YES 14-N&-
LINER: G YES 040
SCREEN
_:-9GTlifl�C_
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (It)
DEVELOPED?
FIRST _
_ °`'` - ;.. _.
HOURS -
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH n.
WELL YIELD TEST It detailed pumping1ELL
METHOD: O PUMPED t tests were done is in-
t
gL.681NPRESSED AIR , formation attached?
O BAILED ❑ OTHER 0 YES 0 NO
LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
8ear-
ing
Well
Oia-
In
FORMATION DESCRIPTION
cooE
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWDOWN
ft.
YIELD
gpm.
Surface
a(•S
�d ✓ b dt rt�8�
�V
(offs
l4fATER O CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS.
O COLORED ANALYZED? ❑ YES ❑ NO
ANALYSIS ATTACHED? O YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAL,
PUMP INFORMATION
TYPE
RAKER
t00EL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME QQ ryry�� DATE
ADDRESS �d, - 4Gtd3iTURE C /
� r V
IN
PUTNAM COUNTY DEPARTMENT OF HEALTH _ a�
e., a. wo:.. �„ �.. w. ....�...�oc%��:�.i�,..,s..«i?-v +a- -•wcrw .'Sm;]�ir.'k..ti .o :- s:1N�.L£:a;Kl.',L,:iY,gs+:..1_� ati: h::�.k.'c�}i . -e^ :,.«G�� �•:.:..:n•ti:; �.rpr •i �.•��•�%e+ .�.•w +r �o:..,.:. u- ;rv...: •awn a.
Owner or Purchaser of Building
1771 2i0
Building Constructed by
Location - Street
�v �Ni4r'1 liALLSy
Municipality
Building Type
,:,�3, - `-/ --�3
Section Block Lot
0o woo D Acne S
Subdivision Name
Subdivision Lot #
GUARANM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that.I am wholly and completely responsible for the location,
workmanship, 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 me which fails to
operate,,for. a.period: of two .,years immediately._: following the date of .approval of the
;j.beltiri- :clte'UL Cofistractiufri - iAiGVi�ct►i%C�° 'LU.L iiC' S' Wage "UISpO:aal SjTSte3T1, Or u;;j'
repairs made by me to such system, 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 Environinental 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 building utilizing
the system.
Dated this /7 day of Q 19 91/
eral Contractor (Owner) - Signature
Corporation Name (if Corp.)
Signature
Title
Corporation Name (if Corp.)
//
Address
rev. 9/85
mk
Sim p� C
Address
11/3Q/94 MF T. COLIFORM -ABSENT /100 ML —
11/30/94 IRON (Fe) 0.103 MG/L
ABSENT
0-0.3 -..
COMMENTS:
BACT THESE RESULTS INDICATE THAT T "(WAS NOT) OF A
' SATISFACTORY SANITARY QUALITY ACCORDI11 �/ T+�HE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS � �
TESTED, AT THE TIME OF COLLECTION.
Fe/Mn If both iron and manganese are Present, their total value ' combined shall not exceed (}.5
SUBMITTED BY:__ 4------------------
Albert H. Padovani, M.T.(ASCP)
Director
�
. `
`
ELAP# 10323
YML ENVIRONMENTAL SERVICES
321. Kear Street
- ----- -'--` -� t2
~
V +/ 04 uVV �Y '
Albert�
`
+'
r/
LAB #: 32.403398 CLIENT #: 4423 NON STAT PROC '
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DEFLORIO, MICHAEL
~~~~
DATE/TIME TAKEN:
11 RICHARD DR
-- -' -` - ' `` DATE�TIME REC'D: 1 �19���~
MAHOPAC, NY 10541
REPORT DATE: 1`�38
PHONE: (914) -337-1494
SAMPLING SITE: SAME AS
^` �
ABOVE LAUNDRY SINK SAMPLE TYPE..: POTAI
PRESERVATIVES: NONE
COL'D BY: MICHAEL DEFLORIO TEMPERATURE~": < 4C'
NOTES...:
- COLIFORM METH« Mp ..'
DATE FLAG
PROCEDURE RESULT NORMAL RANGE
11/3Q/94 MF T. COLIFORM -ABSENT /100 ML —
11/30/94 IRON (Fe) 0.103 MG/L
ABSENT
0-0.3 -..
COMMENTS:
BACT THESE RESULTS INDICATE THAT T "(WAS NOT) OF A
' SATISFACTORY SANITARY QUALITY ACCORDI11 �/ T+�HE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS � �
TESTED, AT THE TIME OF COLLECTION.
Fe/Mn If both iron and manganese are Present, their total value ' combined shall not exceed (}.5
SUBMITTED BY:__ 4------------------
Albert H. Padovani, M.T.(ASCP)
Director
�
. `
`
ELAP# 10323
lV1ZIA11[ COOffff D)WARIVAER `OF HSAL1$
� ` & ` �"� DHYw er W Ht> 'Senloei. Caesal ; N T 161? Ito Ywvlde Fwii- C
` ` • OF.
CO
FOR =WAGE DISPOSAL STEM Fea�tlt r
y�
•. .: �•..• r +N v .ti - a+. ' -. rr �..sa, r �'ti.. �.vv,.. j•+ a:, .._.— {:.� 4 ny :_ ..:•.� _..
swwh e m Naaaa _Sim6d. L4t.r —_ T� Map �o.j :..< '7y": v.
R11111111111rd a =w,.
Dais of Floik" Approval
rr ntts A i ae /�/ . W/1CD�� • lL. ��J7 %J � �`. y Town a -07
above described will be constructed es'shownon the approved.atnendment there to and in accordance with ter sbndards;.rules a regulations o. ' m
County oepartmerit of Health, and that on completionthareof a - 6e►tifieate of Construction Compliance' satistaetory to the Commniploner of Me lthwill
b• submitted to the, Dc Oftni nt, and. is written guarantee will be furnished the ow
' o i; heirs'or 441140 by the bulkier, that tild builder will
epee in good oeMiting eonOttbn•anY v.n ol.feld aawage disposal cyst em duri'
�r � (ij ycarsimmediately4ollowing tMOatc_of•tM Itsu•
ana Of ter. approval -61. tM'tertilleatc o1 Conitructbn. Compllenu of;ahe or
ks the►cto; 2) tlbt:MC drilled wait mNsrxigc0 above
w81 do Iotitid ai'Aamivn on he evaowd_ plan and that seiiWall will M installed i
rrli,'.ruN and rig agTE%ns ; of the Putnam
County pcpirtntcilt. oit He.Rh.
Data �%` Q Signed
�/jJ�A✓
P.E. .R.A.�_
�/
L{eaMe NO Z- ��5�
Address
APPROVED FOR' CONSTRUCTIONt T s approval expires two .y omn the ` .cant 0' ion, of the building has been undertaken and is
revocable for caq" of may nn nded o► modNied vein tonsi ry by
raduires a no it per for diipoW of "domNtk sIni e, a /a►�'
Rev 2 46f
r._ wIth.. Any c nge or fit afgn of eonatruetbn
ply.only.
.LVI88 pate BY .
Title
m
DEPARTMENT OF HEALTH h
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
q..O. - (91 4) 278 -6130
'0 Tr0&' 1T) vV 9M"I X - -RA E Wg
ar�.'4.4
PCHD r4AC-R'tr9.IDSV��1.i9 a Yry ... of rmn... •�
PERMIT # -
WELL LOCATION
Street Address Town Village City Tax Grid Numb r
Ap
WELL OWNER
Name
Aalling. Address
Aprivate
OPublic
USE OF WELL
1 - primary
2 - secondary
,KRESIDENTIAL
® BUSINESS
® INDUSTRIAL
OPUBLIC SUPPLY C3AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL . O STAND -BY
®ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT c gpm/ # PEOPLE SERVED 4- /EST. OF DAILY USAGE 6'0 y gal
13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION O. ADDITIONAL SUPPLY
EKNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
WDRILLED
®DRIVEN []DUG
®GRAVED
[3
OTHER
IS WELL SITE SUBJECT, TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Z:7&f- ee
Lot No. ?
WATER WELL CONTRACTOR: Name ���a��o� Address :
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES io' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
ia�'"E- pTnWPROzRTY- .FRf:Ni:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET ;7e, �
'(date) (signature)
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 requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or ste products from such well drilling operations be contained on this
property and in s anner ? t�•�i grade or of rw se contaminate surface or groundwater.
Date of Issue: 9 ( j3
Date of Expiration - Z�j 19 9 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUI• M COMM DEPARTMENT OF HEALTH
DIVISION • /' •' HEALTH SERVICES
DESIGN DATA SHEET-SURSUFACE SEWAGE DISPOSAL SYSTEM
Owner F= NO.-
e Address 3;?--1 611al A41
Located at (Street) Iq / �e? /'C/ V.*- 1'e tf Sec. Block 44 Lot ZV 2-3
(indicate nearest cross street)
municil
Date of Pre-Soaking 41
Date of Percolation Test !�Z/ �20,?52__
HOLE
NUCER a= TIME
PERCOLATION
PERCOLATION
Run Elapse
Depth to Water Fran
Water Level
No. Time
Ground Surface
In Inches
Soil Rate
Start-Stop Min.
Start stop
Drop In
Min /In Drop
Inches Inches
Inches
/V -
Av.
—3
21)3-1—.12,cl jr _30
J2_
4
4
5
2
3
4
5
NOTES: -Tests to be repeate6 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.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
`U`1
hl
fi ii Tvue
G.L.l /
1°
3'
4'
5'
6'
7'
8'
9'
10'
11'
12°
13'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING aMUNTERED 10's of
DEEP HOLE OBSERVATIONS MADE BY: 0" T � � // i K00-7 DATE:
�. DESIGN -
Soil Rate Used �� Min /1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity OG'� gals. TypeM/MOd.'
Absorption Area Provided By �� L.F. x 24" width .trench
Other
Name � /�/ �� Signature,
Address T �� ����'/"�� SEA
L, r
27xz-
THIS SPACE FOR USE BY HEALTH DEPARZM U ONLY:
Soil Rate Approved
sq.ft /gal. Checked by Date
_.- .r_.:_ =J
PC -1
PUTNAM COUNTY DEPARTMENT O F HEALTH
�'4rc..1/,l`TT111{�� .1 'A'i1A / �lA nr „n _�►�i'. .+'nn a n i::r;�T�n !. �:•: � - "
«. ...,. :.::i:.'c'..o,.___.......::a�.. -_ -v .I•�� .:..+.r��...�.�...,. ���...'.5;: /�i "�...,. /...- lip ?��wi:: �aj»r��_._C °.:r....;L �`�����'� .. _...�:w:•�.-- -�. --:
1. Name and Address of Applicant:
AV
2.
Name of
Project:
J� �S
3.
Location T /V /C: /:�, /,;7
4.
Project
Engineer:
��La
/�irh
5.
Address:
License Number: 2 y 9-ps-
Phone:
6. Type of Project:
Private/Residential Food Service Commercial
'Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Review (SEAR)? Alo
Type Status (Check One) Type I.. Exempt
Type II. Unlisted
8. Is,a Draft Environmental Impact Statement (DEIS.) required? ............. /✓o
9. Has DEIS been completed and found acceptable by Lead Agency? ........... '
10. Name of Lead Agency
11. Is this project in an area under the control of local planning zoning
3
12. If so, have plans been submitted to such authorities? .................. y.!f>
13. Has preliminary approval been granted by such authorities? Date Granted: ,1017
14. Type of Sewage Disposal System Discharge......
Surface Water ✓ Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index number (surface) ...........................................
7. Is project located near a public water supply system? .................. A✓U
8. If yes, name of water supply. Distance to water supply w'J6
9. Is project site near a public sewage collection or disposal system ?..... A
0. Name of sewage system
Distance to sewage system 11411
1. Date observed: 23. Name of Health Inspector:
4. Project design flow (gallons per day) ...... € 6,e ..........................
A.
2.
�. m ,S n _�f.�tn :Jn'� li��ant`�i�YharnnvGl im n in. C a CG1CCl Per m +t r-aqu 9
26.
Has SPDES Application been submitted to local DEC Office? ...............
_
34.
27.
Is. any portion of this project located within a, designated Town
or State
Alel
-ew's 1f: a .c.5c.0 of !! % 7; pe? _ ..., . , - - - ., _
wetland ? ................ ................ ...............................
a..
28.
Wetland ID Number ......... ............ ...............................
Tax Map ID Number ...............
... ....... ....................
29.
Is Wetland Permit required? .............. ...............................
Alo
Has application been made to Town or Local DEC Office? ..................
30.
Does project require a DEC Stream Disturbance Permit? ...................
31.
Is or was project site used for agricultural activity involving
application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ........
YES or NO
A10
32.
Is project located within 1,000 feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal
site or
Ala
any other potential known source of contamination? ..............YES
or NO
DESCRIBE:
33.
Is there a local master
plan or file with the Town or Village? ...........
34.
Are community water, sewer facilities planned to be developed within
15 years?
-ew's 1f: a .c.5c.0 of !! % 7; pe? _ ..., . , - - - ., _
`'
_ ...:. Al.
a..
36.
Tax Map ID Number ...............
... ....... ....................
37. Approved Plans are to be returned to: Applicant d,00' Engineer
If the application is signed by a person other than the applicant shown in Item 1, the
application must be accompanied by a Letter of Authorization. Failure to comply with this
provision may be grounds for the rejection of any submission.
% hereby affirm, under penalty of perjury, that information provided on this
form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of
the Penal Law. 1 1,71
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS:
04 C-
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION ,OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET for CONSTRUCT AN PERMIT - I
fil/11 .6riwwl N'.1 ;.:_,.
z; r.• . .�. v. .r .+mow -'' :..i...a a:.
BY U " DATE TAX MAP #
Y
DOCUMENTS.
PERMIT APPLICATION
PC -1
WELL PERMIT;W PWS LETTER
ENGINEERS AUTHORIZATION_
DESIGN DATA SHEET(DDS)
DEEP HOLE. LOG
PERC RESULTS (3)
PERC HOLE DEPTH
CORPORATE RESOLUTION
PLANS THREE SETS
HOUSE PLANS - TWO SETS
71 VARIANCE REQUEST
GENERAL
LEGAL SUBDMSION
SUBDIVISION APPROVAL CHECKED
PERC RATE
FILL REQUIRED
CURTAIN DRAIN REQUIRED CDSTANDPIPES
EX- APPROVAL SSDS ADJ. LOTS
-1 WETLAND (TOWN/DEC PERMIT R & D)
DATA ON DDS PLANS & PERMIT SAME PRE - 1969.- NEIGHBOR NOTIFIFICATION
CD LETTER BI/ZBA
ED DISCHARGE (OK)
Wffi PERC & DEEP HOLES LOCATED
REPRESENTATIVE OF PRIMARY AND EXPANSION
EXP. AREA; SHOWN; GRAVITY FLOW, SUFF. SIZE
m IF PUMPED PIT & D BOX SHOWN & DETAILED
HOUSE - NO. OF BEDROOMS
EZ WELLS & SSDS'S WAIN 200 FT. OF PROPOSED SYSTEM
PROPERTY METES & BOUNDS
HOUSE SETBACK NECESSARY (TIGHT LOT)
HOUSE SEWER - 1 /4 "/FT. 4"0; TYPE PIPE
NO BENDS; MAX. BENDS 45 W /CLEANOUT
FILL SYSTEMS
YBARRIER
r T HORIZONTAL: SLOPE 3:1 TO GRADE
L SPECS
TH GAUGES
L PROFILE & DIMENSIONS
LUME
TRENCH
LF TRENCH PROVIDED
60 FT MAX
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
��.100 Y-Q_ . FLOOD ELEykTTON - FIELDS
R ,UIRED DETAILS -0N PLANS' - °_.._•_......_ _ _..�..._ 2` :.,- ..,.�, T Ord �L 'C� Tf1D 1
lU' 'TOfL.�l�i�1VL�vlY1,•1':r:lvi i• a' ti..: �, ��-. t-_ F. .,k- TT....Z::.........- .a......
SEWAGE SYSTEM PLAN - (NORTH ARROW) 20' TO FOUNDATION WALLS
. SSDS HYDRAULIC PROFILE M GRAVITY FLOW 100 TO WELL, 200' IN D.L.O.D., 150' PITS
D/ J BOX CD TRENCH/GALLEY m P- PIT DETAILS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
SEPTIC TANK - SIZE, DETAIL 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
WELL DETAIL, SERVICE LINE IF OVER 10' TO WATER LINE (PITS -20')
CONSTRUCTION NOTES (GRINDER RATE) 50' INTERMTITENT DRAINAGE COURSE
DESIGN DATA: PERC AND DEEP RESULTS 200 FT. RESERVOIR, ETC.CD 150 FT. GALLEY SYSTEAfS
TWO -FOOT CONTOURS EXISTING & PROPOSED SEPTIC TANKS
DRIVEWAY & SLOPES CUT m10' FROM FOUNDATION; 50' TO WELL
FOOTING /GUTTER/CURTAIN DRAINS
COMMENTS:
WELLS
CD 15' WELL TO P. L:
.
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