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631- 589 -8100
84. -2 -27
BOX 33
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ILL. I
04373
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Located
PUTNAM COUNTY DEPARTMENT OF HEALTH
L86 Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
;z C.H.D. Permit q - -� - --
OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL
.: % ;'os= - �• �., Town or V e
01P)a AOnd QPVP / t7a, j9
Owner /applicant Name Formerly
Melling Address AU000• L" /•3 fi� ZIP
la J 12
Subdivision Name fc40a'9. Subdv. Lot # Z'
Date Permit Issued _0,AZo; Ve/
Separate Sewerage System built by_1�7"Z 0 V14 —r0'/ Address ✓r/��P �- /
Consisting of l%%%L% Gallon Septic Tank and
Water Supply: Public Supply From Address
on Private Supply Drilled by Address
Building Type F P Has Erosion Control Been Completed?
Number of Bedrooms J Has Garbage Grinder Been Installed? - odg�__,
Other
r
"• E
I certify that the system(s) as listed serving the above premises were constructed essentially as`shown�on, the plana•o the:.cpmpleted work ( copies
of which are attached), and in accordance with the standards, rules and regulatio i accordar % th.the filed plar;- "a-t}e permit issued by the
Putnam County De/partmenntrOff H�Heeaalth.
IR
Date ! !✓ ! // Certified by ' r' P.E. R.A.
Address O y License No. ��✓
Any person occupying premises served by the above system(s) shall promptly take such action as may bA ,ecs�6 , o secure thcorreaIon of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null an&,Vold;a5 tcon.is , i pudi,: sanitary saver becomal
available and the approval of the private water supply shall become null and void when a public water se+t+�l9�peeomae';ivillabN. Such approvals.;`-
subject to modification or change when, in the Judgment of the Commissioner of Health, such revocatbn,rhtpol lcatloA,or change its nne�cessarr "yy.� , ,-
Oats /-719V �.�, ...� —�� Title ✓` y
a
l� ®11111M lid
n� "i `> )D�ci�as st Bas9W 8sn1e�a. Cagmal.11 t. low A is 011P OO1Q1L1lICi�r
BT CA `
�G Lai Y 'PICK lllfa), � �.� —Nub
o...dA/!� ew�-- �Q1�..�! .%/%ai'►� -0 ��c% CO/� Qo....� ❑ l�..w. ❑
Data ed hevlwa Appmal
YIiD AAAPM V 1 % aP G
— _ n__L t__1..1.... A....rnvnri 12--76 Fee Encl osed o Amrnmt
•++rs rJN�t`C�{D� �'
la Aria M Sas1Na► Oar DeptA Vsfns
140nbw of godmo ` 3 �/�r/��/�� WOW �► G P D (YO�} P® P1 No at b Rewd"d whin M Is oweebMd
Jj�rda tatraoga ! ➢ofit� Ia otfta" atLQQ_)s@s i !no TO*
To bo o wsYlo bd b,_2Z2 A4
an. 2!;� --idwab sopb Dad"
Under
1 fepraaant that 1 am wholly and Complsitaly nssponsibte for the design and location of the proposed syttem(ata I) that thew rata saw. • dl owl s stem ION rm"am
aheve alml bed will be constructed as shown on the approved anandnseht tgere to and In accordance with the standards. rust M ►qua o
panty Daaort ad of H N r4 and that on comIlooti0n.thersef a °Cartifliate of CoaWl dish CoMpllanea* wtisfecto►y to the ComnNwlOW of Heallhwlll
be fMsnR M to tow pNMshard. am a wraw fplararlta'a will be furni*ad the owher. his sueamors, heirs or awyns by the burner. that wM beft er win
pttea N (1Md .oPdratlM "am any dpt of ON aMw/a dbpdwl system duriq tM.par oft" 12) vows knine"toly to110wme thadNo of the 1oµ
e ee M the go wee of tM drtNtata of CaKntrudioh t;0anpill w- of the or I syatdfn any MINING thereto 2) that the Oriume well dealers" dove
sew be weaa�ta as *of7?7 moo pMn and that aid well will tee In � tth the standards, Ms and raW Ons the Iutnanl
�► P.E.. X 11.A,
Daft i BA t Lim= NO.
APPROVED ROSt f:Oa1fT11tJCilON� 7adt 1 sap two years hoar the data issued unwss Condru n of the bulldhM has been undertakM and It
M *WAR" a snodNMd when Con"llead nwessary by the Comminloaw► of Health. Any chenille or altaratlon of -Construction
gggUar late water supply only. f�
NOV 09 '91 14 :06 P.F.ZEAL.INC.
P.2 /2
�L
BREWSTER LABORATORIES .
(014) 89S-1930
- WATER ANALYSIS DEPORT ---
SAMPLE NO. 8175 TEST WELL
SOURCE: Phoenix Industries
Foot Hill Streat
Putnam Valley, N.Y.
COLLECTED: 10/15/91
BY: P. F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Colitorm Count, MF Method per 100 ml.
This result JndkAtes the souroe of the sample was
of satlsfActory sanitary quality Aen the sample was collected.
10/19/91
y` /
PUTNAM COUNTY DEPAR'I1"ENr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purchaser of Building Section Block Lot
&- NJV-Q-
Building Constructed by
Location - Street
,//
Municipality
Building Type
Subdivision game
Z
Subdivision Lot
GUARAYM 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
"Certificate of Construction. Compliance" for the sewage disposal system, or any
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° .� - .�.. _ ..... ....4_ . ... _ .. .
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 day of k)c-,J 19,1 Signature
C Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
r
r
Corporation Name (if Corp.)
R:.
OE =10,01.
WLLL I;Ur1rLL11U1V r%ZrVr%1
�C a
o. DEPARTMENT OF HEALTH �+py
Divi:sion.Of Envranoiet :.a�'.,- Realt�h. ;�7�4,
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: FOWNIVItLAIMCIry TAX GRID NUMBER:
i'oothill Street Putnam Valley
WELL OWNER
NAME: ADDRESS Afitffony U'ullla ro
Phoenix Industries,PO Box 134,Crompond,NY10517
FC03 RIV ATE
UBLIC
USE OF WELL
1 - primary
2 - secondary
13 RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 525 ft. I
STATIC WATER LEVEL 41 ft.
DATE MEASURED 9111 191
DRILLING
EQUIPMENT
f3 ROTARY 91 COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH 82 fit.
MATERIALS: IM STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH BELOW GRADE 81 ft.
JOINTS: ❑ WELDED ® THREADED O OTHER
DIAMETER 6 in.
SEAL: ® CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 19 1b./It.
DRIVE SHOE: ® YES ONO
I LINER: G YES ®NO
SCREEN
DETAILS
__....._ ..
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVE0PED7
FIRST
� � --
o: YES ONO— •
..._ .
' HOURS_'
SECOND
; =:. r.'.
- ...:. _ . -. -_, . °R
_ .._ . -.. .
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED tests were done is in-
0 COMPRESSED AIR , formation attached?
O'BAILED O OTHER ❑ YES O NO
WELL LOG
If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
l
water
Bear-
ing
We1l
Dia-
meter
FORMATION DESCRIPTION
CODE
ft.
ft
WELL DEPTH
ft.
DURATION
hr. min,
ORAWOOWN
ft.
YIELD
gpm,
Surface
6
Dr
lli
in overburden clay & bould
rs
H
t ipck
at 651
525
6
400
5
1 65
82
Dii-11ing
in rock set casing grou
ed
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? O YES ONO
ANALYSIS ATTACHED? O YES O No
STORAGE TANK: TYPE WellXtrol 250
CAPACITY 44 GAI..
PUMP INFORMATION
TYPE G»bmb . rs i b1_ CAPACITY 5 a
Gould 420'
MAKER DEPTH
MODEL 5ES07412 'VOLTAGE 23_0HP1�4
WELL ORILLER NAME P.F. Beal & Sons 0 E
ADDRESS P.O. Box B stci 1/8/91_
Brewster,NY 10509
J /6y - / v
T tC. 4
-- Ts s OR
C. ��' �1CC5 f -���'1 Giii-.. -1 1 ^�_C° Oi �C-1 7 �T_
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r -� 1r_ ==+ a5 Per r-
'
b_
F= i ?T cc - Dam cf plac=*� ,it.
IL G_rPITH
LOE Wes=
C_
1r� �? soil r_ct. st= Tc=
area
E _
j Nc =- CCL= °�:Jc-
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ct -
�_. - DTs -Cc ?-L rp
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t
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c_
r--YcS ,rCCe_'i C- -CLL-
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h_ S--face W-="ZE C =CL= -__C_l
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER,'CARMEL, N.Y. 10512 (914) 225 -0310
APPLh*C TI0N"T0d " CONSTRUCT "A"W ifiE22 JELL'
PCHD PERMIT
WELL LOCATION
Street Address
Town/Village/ C t Tax
rid Numbe
WELL OWNER
Name Mail �• Addres ��� Private
f lIN`Q. e %cif/ �x x O Public
USE OF WELL
1 - primary
2 - secondary
OCRESIDENTIAL.
0 BUSINESS.
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM p TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
0 ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD: SOUGHT. gpm /# PEOPLE SERVED, 41 /EST. OF DAILY USAGE _UV_ Ral
13 REPLACE EXISTING 'SUPPLY ❑TEST /OBSERVATION Q ADDITIONAL SUPPLY
ffNEW SUPPLY NEW DWELLING) CI DEEPEN. E ISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
v
WELL TYPE
DRILLED
3
DRIVEN
DDUG
O
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: _D*A11,17 SC
Lot No. 2i-
WATER WELL CONTRACTOR: Name %�(=�. Address: 91L11 J'A4_
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM. NEAREST -WATER ! ,]
N
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
hdfl 1�fON SEPARATE SHEET
(date) (si na 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
thirti� (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 waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
:! a of Issue: 24 19
,?f Expir9flion 19 Permit Issuing Official
s Non - Transferrable White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
AFFIDAVIT CORPORATE- •0 U'* ER•kPFt;- 1eAT!DN`="
+'+Ytq l� • t 'di :r�(t "ch,31t"'�Y': ^ll r`•Y _
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
I,
represent that I am.an officer or employee of the corporation and am authorized
to act for
(NaQ of N rporation)
having offices at
Whose officers are:
President:
(Name -and Address) N
�r
Vice - President:
(Name-and Address)
Secretary: -
__ _ (Name and-Ad "dress) -
Treasurer:
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts relating
thereto.
Sworn to before me this day Signed: C• ---r.�
- `
of 19 Title: L _
e
Notary Public
8/84
rnorate Seal
C.. EZ:tL7-=- -
DIS�:CSL
SUp 9:.Y URFA=
F-V -
of cwr.—=�; t LC C=)
YES I No vcca'`- =-- // `�, - -c=
Z: Ica 11 •
Plans sat:s
C"
ces: aata saee'-
11 nI
Czrs�:Stan-*
Per G^i=
cz
V7
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i 00
ell
"0 ft- 610,00,
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20' t-o Van's
loot jz 200' in D.•.C.D, 1-L0'
loo, t.0 5_:.a Fr _zr_Llr=- (;rlc.
13' 11C Dra
10, t:3 ��te-r LIne (zit-F-2-12'
50' iz.
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31 -. • I. -
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STP,EET:
BRUCE FL FOLEY, R.S
Acting Public Health Dire-; ,
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509 Qb
(91Y) 278 -6130 / 47
PROPOSED ADDITION APPLICATILON = (RESIDENTIAL ONLY
TOWN ��/ �°.�� TX MAP � � y —2
N NMI E f �vp d�i/iGs h�o� PHONE � � --5 39:5G PCHD PERMIT #/emu'
MAILING ADDRESS
Description of =Addition G
% e,/ ";W , 12-ool,
Number of existing bedroa-lis Proposed number of bedroom
from Certificate 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 PL9 NAM- COUKIY HEALTH DEPARTMENT,
4 GEN:1/A ROAD, BR= 4STER, NY 10509, Phone 278 -6130 with the following information.
Certif?e�•Cfaec{_,f9 r_5100..0:0.
.:vetch of existing floor plan (all living area including basement, if any)
Non - professional dreeiing is acceptable.
Sketch of proposed floor plan.
Non professional drawing is acceptable.
4. Copy of survey showing well and septic location, to the best of your
knowledge. Include date of installation if known.
Include all yells and septic systems within 200 feet of property line. Any
questions please contact this office.
% Copy of Certificate of Occupancy from Town or Certification from Building
Department' of legal bedroom count of dwelling.
,,4rl 7T FFICE USE
�ments and /or conditions
�2 moo- ��,:s� -3 •,�,s 3.� --- � �-- � .�.� � �� �
application
August 1995
July 1996 (Revised)
A_NDCVER ##8.0 �.
SEC .._..gin DND . - .ELDDR . '.. ., ._ — -... � . -) • • �.. q . ... Vie-
�^
8/8/91
SCALE: 1" = 6'
GUEST
BEDROOM
SECOND
BE
OFFICE
STORAGE
r C-- &
T� ggoo,
=� —
TV ROOM
1
_ V 9
1
1 sf FLOOR
LIVING
1,ppro(6ed as noted for conformance wl
applicable Mules and pebulations of thF
"atnam Co ilealth Department..
'1, , tuxa A9 MIA
fit/ /` c �` 6 •�7e t� �l 47 /
i�
ANDOVER #8.0 SCALE:
5/3/97
MASTER
BEDROOM
KITCHEN
®a
S®
(01
GYM
DINING
I
LIVING
lluio and Regulations of the
e De tment:e_
'i.s��±t ;rw A Tltlp t :°
r
ANDOVER #8,0 SCALE:
1
5/3/97- 0 -
KITCHEN
MASTER 00
BEDROOM Sao
F
MASTER.(d
oa
T
Oil 0
feh
DINING
m
LIVING
liote
for r conformance with
--nd Regulations of the
lth Department,
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DIVISION OF ENVIRONMENTAL HEALTH- SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
_ d Owner- `.
Located at (Street) /" �C/�1�% i�r�i Sec. �/ Block Lot
(indicate nearest cross street) ) n
Municipality WatershedI j i/ 121
SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking Date of Percolation Test
HOLE
NUMBER CLOCK TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water From
Water Level
No. Time Ground Surface
In Inches Soil Rate
Start -Stop Min. Start Stop
Drop In Min /In Drop
Inches Inches
Inches
1
2
5
1
0)
4
5
1
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.
rev. 9/85
r]
TEST PIT. DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO.
11
21
3'
49
51
6
71
81
91
.10,
12'
13'
14'
INDICATE LEVEL. AT WRidi G'ROU'NDWATER IS ENCOUNTERED
HOLE NO HOLE NO.
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:
DATE:
DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided
No. of Bedrooms 3 Se tic Tank Capacity /02��_A _ gals. Type
Z;)
Absorption Area Provided By L.F. x 24" width trench
5m r —
Soil,-.Rate , Approved
ca__ "I'
U3 I--
sq-ft/gal. Checked by Date
{
- Ic:
PUTNAM COUNTY HEALTH DEPARTMENT _ .._ ... .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M:- ,Simmons, M.D.
Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
j F
INSPECTION
NAME �� �✓ Viz- _ Orig. Routine
Orig. Complain
ADDRESS :.. �� / /5'- Z Orig. Request
No. Street Town TH No. Canpliance
_ Complaint Camp
MAILING :ADDRESS _ Final
r •a. = P.O. Box Post Office Zip Code _ Group Illness
_ Construction
'TEiEPHONE
>v
Reinspection
>PERSQN ,IN CHARGE _ Field, Sampling Only
1 aMF UVIT [, Lr#VrAU
Name and Title
a
DATE G TYPE FACILITY
r = .
TIME � �� TIME LEFT
Field Conference
Other
Explain
etoo�lll-
'g- 6 3f1�K5N I �1
TO
7
:A.1
L
i
t iln to , Et
"This is to certify that
the sewage . d sJOSal system was constructed as indicated on this plan-'and
that the system was inspected by me before it was covered over. :.The
system was constructed in accordance with all standard rules =:and
regulations of the Putnam County Department of Health and the New York
state Department of Health." 4:
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"This is to certify- that
the. sewage disoosal system was constructed as indicated on this plan and
that the system was inspected by me before it was covered over. The
system was constructed in accordance with all standard rules and
r =_ablations of the Putnam County Department of Health and the New York
StateDepartment of Health."
P.
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th
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ft nam C-Gun 'Y
f % � L
.y
"This is to certify- that
the. sewage disoosal system was constructed as indicated on this plan and
that the system was inspected by me before it was covered over. The
system was constructed in accordance with all standard rules and
r =_ablations of the Putnam County Department of Health and the New York
StateDepartment of Health."
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