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A27 184r-- '� ,- --- -.. —=---�-� - . The Distr�ct Healfh Departmen�� � . � CASWELL - CHATHAM - LEE - PEiiSON COUNTIES Water Supply and Sewage Di�posal IIKPROVEM'ENTS PERMII: No � t p !.C'f s G./ — � owner: �--i �'�'-',.� ���wn� �.r �_ Location: ' I �?--�-- ��i��� ('sntrartnr� t--�s� � Wat� Suppin Prlvate ��c'`� Public S�aags Disposal Faeili!las: Na bedrooms � r Dishwasher. Disposal, washing machine, other sutom�tic appliances � � '� �^" � � Size ot tank: � i f f'^ -� Nitriflcation line: , ...�'-- � � • � C � ��*--��I�T'�'S Other disposal iacility: Water supply and sewage disposal lacilities loeation, installation and protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years and ,shall be maiYr tained by owner in such a manner as not to create a public health hazard, Septic tank and nitriflcation line MUST BE INSPECTEI} AND AP- PROYEII BY A MEMBER OF TFiE DISTRICT HEALTH DEPARTMENT STAF� BEFORE ANY PORTION OF THE INST.�►LL�ITION�S COV- ERED AND PUT INTO USE. � j ; , � j' f • i li ; �,^,• � r j / 1,f t+ ��, �,� �Lq/ts-x'�f Date approved• Signe ���� � y'_ o� ��i Well• r r'� ; �'��''��—' n Sewage Disposal• Count � � '' . � �f�`'.•�-^�.}�= ���—_��:f„/�.. � i 1 • v.,-�i. HY' � er or� ' representative) C@I�C82@ O� CO�I@�OA I� � � � �� � . . . -� n�j `� ,. Date Approved:�; �'' k� By. r �`/s '� �; ; �anitarian (OVER) . . Location of well" and sewage disposal facilities aketched ast beci�. j � r.; ;. � _._z � , � � - w x �o � � _ � � .o .'" -_ � - y. : °= � � - ' � _= - . � i i � _ - � - _ r .. -- r 4 _ 3 i - � �' _ - . D � y a - Dm " y� � � —_- D r - O -- � � - � � -- � - D M i R. � y O _ w � r. y - � �° � �. � �.. _. w .+. - � �' o �, - y y � b = w •, � . ... 5 y �"• : (D y - _ O � � m� �. �. a K _ „. , .. . . . . . . _ _, . - - _ _.... .. .... '� . . , ._ _ , , � , ,. , ,�. .�_ _. _,__..._. ._ ..__�_,..._. _..._.... .. __.___ `: : : �� :,: :: ...��_ __._ ... . . .._.. - .._ . _ . . .. - , ; . . . , - _: , , ` ._ � ,, �� � � � . _ ,;; � s � �; �� WELL PERMZT � . '7 �', { Caswell-Chatham-Lee-Person Counties . . . . ;” DATE IS UED: ATE DRILLED:�"'r� �� COUNTY: "�'�- OWNER: y��� � ROAD/ TR ET: ADDRESS: �' 1"`+'" PERM�T�D T�� ONEly DRZLLING CONTRACTOR: '���- � NAME ADDRESS WELL CONSTRUCTION Distance from Nearest Property Line Distance from Source af Pollution Total Depth: Ft. Yield: GPM Static Water Level: Ft. Water Bearing 2ones: De th• Ft. F���' �Ft. Casing: Depthc From_�to Ft. Dia er: ."'1 Znches TYPE- Steel Galvanized Steel If Steel, does owner apprQ� Yes No Weight: Thickness : �� Height Above Ground: Inches Drive Shoe: Yes: Na= Were Problems Encountered i.n Setting t�he Casing? Yes_ No_ If 'yes' give reason: Grout: Type: Neat S d Cement: Concrete Annular Space Width � Znches Water in Annular Space: Yes No A� hfethod: Pumped P ure . Poured Depth: From to __�� Ft. !laterials Used: No. Bags Portland Cement weight of 1 bag � lbs. If mixture (sand,�g'�avel, cuttings) - Ratio: to ID Plates: Yes No Chlorination: Yes No 4 x 4 slab Yes� No I iiBREBY CERTIFY THAT THE ABOVE INFORIiA?ZON IS CORRECT AN TBAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W GULATZO SET RTH Y � � CASWELL-CHATHAM-LEE-PERSON DZST. HE � �O �pplication Date: �' ��"� 1 p .p� l � G�� c� ' TaY 1�Iap: 2 �nount Paid: j� Q , Q (�� 0 . � ���6 ,p Q �, � 3 � Farce: #: __���!� Receipt�#: Q 5 % ��( 0��� I 1� ,,�o �� �"�� `� 1�"" � �� �J��� �• � � � vT U �� ' ' '� e. �� Y �. ` � � �--�=_�__�'- �� cC� � ���, �' �.T C � � b . ��:az�-a>:L•r�c�ra.���.c-.Tr.i�t:-«=nT1 IE�L.�� �.1a:1�z � 1�,0 M l N S U 1����ic����n �oa- �e�vie�s (Septic Systems and Wells) � �o�1J � u�,s t oe�l'� Sea-vic�s �e ues�ed ��mprovement �ermit (Site Evaluation) � Constraction Authorization �200.00/$300.00 (if> 600 g d) (Fee is dependent on the tyne of system ermitted) Io ' e e eplacement or Building ,�tidition �J Permit Revision. $1�0.00 (i ite visit re uired) � $75.00 - � �e it lacemeat/�2epair) ❑ itepair of ��is€ing Septic Systean ' $300.0 /$200.00/ 75.00 �No Chartre � rvic�s Req/ueste�l �y: / r I, n � ��� " Name: G.. U � Y 7 � � � �'i � �l Phone # (home): � � � � � � `7 `� �' ��-� Address: 0� L 1�' s � (work/cell): / � �,�-5l 89R , NC 2 7S 7y ����5� JUSc �-6�-X � Zjl��m� �nd ada�r�ss off z�arr�mt ow�nea� (i�' dii$'�r�nt ghan ap�lFcant): Name: ,---- Address: / ) �'�og�eq-dy �3escrnpt�on: Lot Size: / Q � � �ubdivision: / '� ot #: �! r?t3c 7���v Acj�-ess and/or uections to Pro rty: 3�� � � Q � l.b a' �il) "�3 �� J'1 � L, t S �i • 0 A� � ol�-� ' �U ! A1 S`� I> 1'' ��?� �� 4c P2 / S�,l/ I �M �G�- ��v L[= FT roposed Use and 3�pe oi Structue-e: �ri��--,� � 1 s J} 6� r� -�/'r: T L�o c. � ��j pt� � To R�sidential Business/Type: -'` � Other —�— ���5 L s Number of bedrooms �J / Number of people served (seats/employees): � P�. i f� S� C� LL Basement: Yes ✓ No (with plumbing: Yes ' No _� � L�9J�' C Cf!$ �/��i� G age disposal: Yes No �� � 5) VVatea� Supply: / � .� Private Well �(Proposed Existing_) W4�v�� 1-�% 1D €��i'C,�/�K'G� L�'1 S� iN�-� _ Community Well: Public Water System: . Are there wells on the adjoinin� properties? T10 Yes �(please show location on site plan) �� . I�T�oie: A co�a�leterd nn�ldcation mus� n�d�s�o incluc�e: �� �1 �lat/site �lan of 11zs �r�perty �,�iat sltotiv� �: o�er� difr¢e�.sdons canci the siz� �rdad �ocr�tion �f rall �ro�osed siructures. . � �� 5igneci capy of tdae `��P ����c�ratio,�'�OpiBB v��'t�,j183?a �laag P��e �a-operiy i� re�e�'y io ve. evadur�tesi. � a�a �aabmitiing th�s ��oincation #o �-c�uest 3ervic�s �'roar� t�e �Qr�on �au�aty ?-�ealth �epa�-#�ne�nt. � uncersta�nd t�a� ig #h�e infoa-�ation p�ovide� is inearr��t �a- i� �t�e �nte is su�s�e�ue�n�ly �l�ea-er�, or if th� �ntenc�ed u�e char,g�s, a�� per�ar�#s �ud apprava�s shal� %ecame invaiid. � - � � �a;���u�-� {Owner/Legal Representative): � ��r� : � � S � 10i0S Person County invironmenial Health, 3?5 S. �ilor�an St., Suite C; R�Yboro, NC 2757� (336-�Q7-17°0) ; ��,� � ; l' 1-� �-�'���� ,Y� 1 •��.�� ��- T �� � � �-�1.�I �� ��-����„-„ „-,;-�, <e�.�.,�.I1 I�3L ��.I1�Ila Applicant: T�H , ap � ' :.rc�el ; S u, � diiui s,i o�n ' .�.s =S�ct+ian'L� t �aapra���en� ��s�it � ��s�at �i7�d �or ✓ 've 3�e�s �To �zpn�-ation ,/ �Iate� ��a i � Type of Facility: New Addition �p y ## of Occupants # of Berlrooms y3 . Proje�ted Daily Flow ��D g.p.d. Proposed Wastewater System: � Type: �a Proposed Repair: ,���./� �' TYP�' .�_ Permit Conditions: xOwner or Legal Representa.tive Authorized State �Agen�t: Date: �/S The issuance of this permit by the Health Departm;ent in does not gvarantes the issuaace af other permits. It is the responszbility of the � applicantfproperty owner to in sme tha# all Person County Planning and Zorning and Biu'lding Inspections req,�; ..TPm�++ts are mei This Impro�vement ��r�ii � s�jec# t� r��ocaQion if tlae sii� plan, plai o� t9ie int�aied u�� c�aaQges. 'i7ne Ina�roveffi�nt Pe�cffiii i� �o# ai%e#e� by � ci��nge in ownerslxip of tlae property. �is �ernei# v�as issaaerY in cm�pliamrx v�itix th� p�ovisions of the 1'iortla C�lina `Lanvs a�rad Rules f�r 5srvaarve Tres��nem¢ a�nd ]�isn�sad Svsterns' -(15A PdCAC 13A .19Q0). 1�leitfies� I'e�on �mannty mar t�e Em�vir�nxsa�n�tal �e:ilt�a Speeialist' wasr�a� tia�t. the septi� ta� sys��at �ifll c�ntiaau� ta fun�on satis�ci�a�ily it� tix� f�s�re oe'tlaai th¢ w�teS supply vv�i! remaiaa:potai�le. - -- ... � . �� Authoriz��aon �� �oa�t�c�'��e�a$er Sy����aa (R�q�e�rl for ��ic�g �'e�i) * Ses site plan and additional attachments (__). r�"/`� �✓T,n%� _ . �/ � Proposed Was�te�vvater System: �l�j��✓�l�if%iLL �Du�D, Type ��,j �Iaste�vatex• Flow �:p.d. New Repair Expansio� i ���� LT�2: g-P.d1 ft 2 � Type of Facility: � � Basement _ Yes _, l�o � � , �aste�va��� �yst��. R�a�effi��ts � . �✓�t-✓ �✓�,r/ - �aa� Siz�: Se�stac ��ak: %bD g�i �� i�c: /060 ��1 �Gx�e Trap: gal ��ai.an�ei�i: To� �ea: 5a� ft ��'ot�l Lengt�a � � lY.��i�aa� �r�ncis i)e��ia �a T�eneia v'Vialt�a #t �aaffi �o� Coeea : in �is�utaon: �3is�iribni.ioaa �o� Seriai �istri�ntion �ga�a 'Tren�a Se�arra#ioin: �t Press�re Ibl�ifmflei ,. r ;� ��: r �c . � //ti . � r %► 1 � � / //I , -��xthori�e� ��#� ���t: �— Permit Expiration Date: Date: ��[ >,� � The type of sys#em permitted is V Conventionai '�cc�pted Altexnative. I accept tiie spe�ificatians of the permit. � x����/.����i ���g�s����ave: � ` Date: ' PCSD rev. 11/10/OS NEMA 4X Simplex Contml Panel 4" X 4" Pressuze'Treated Post__�,,i ; Sloped To Shed Water �2" Se aration � b" Cover • ..� Inlet F:vm Septic Tanlc v 4" SCH 40 PVC Pipe P z � E12CtY1C'dl COYld111t �^- �• ; Accesa Cover• � •• , ' . ; � .) � ; . _ � 1 I.,,i _- : •�.� %` .: �, Opening Filled With Anti Siphon Hole. � Portlarid Cement Crmut �� j��� . Check Valve � Hig� Watez Alaxrn Level " (S" Separation� ; , High Level- Puxnp On ' ' +�VaporLock .• .. ' � �� Hole • . � Drawdrnvn �Up Hill) 1. Low Level -Puznp Off �_' ' ,: Ihut SealBoth Ends Of The Con,duit -r- ' 24" Mininwm --, .. ., • . •'r:"T' Threaded Gate Valve Zip Coxd Ties 1 ' Pxecast Concrete Tank 4" Cozucrete ;.; (MaterialStzength>3500PSI) Block ' �:�,: � � : + •_ .' • _� . ' ' . . : ' �• ' , . . '� � Person County Environmental H�1 325 S. Morgan Street Suite C Roxboro, NC 27573 ����-,�Q� ���� �O 27- I �$ `� Coxtcrete Risex b" Sepazation . •,' - , ' ;r „rt fi•1:"""^—,– '��-Portland Concrete Gmut • Iviastic - - ' . ' f' _ . 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Pcnmer ?�rry +�`� . � . � �'�' rs:ar� rc ����i �cr � � tn�c ir�a m-� s.�a�.� � ��"i(1NiY �1� canm��a3 cr ;� : �av Pei'�011 COUf1ly EtN�1911�81 HA81Q1 (� /�� d✓ ,,�9�'y� r,vrUG U�� ��li�%7i►✓�� .���i"�� �`.�f�'ti :�5 s. �0�91'f � Z�'� �/�'�/ l ���iL�� s-'O�. /✓f�✓ �c`�'?�� %'/,�n% �/a Suite C � i�c�+a� -T�✓� � � Roxboro, NC 27573 d�o.,� rr i�i���� �o�. ��/ y✓�-z.� �9 7- i 7 ��c� -��✓��• f ;�3� �'�!�✓�� � �j(i�� � ,� � �/v� 7Zt 3 � http://gis.personcounty.net/connectgis/Map/PrintWindow.aspx?Map=http://gis.personcoun... 5/19/2009 �� � `--•. , .� ��1Y ' � � � ���� 1,L..rrflCii�'ZI.�i�CD,31L.7�'n.U"✓'IC�I.¢c�A.JI �t�"'✓�0.111�3CIl. Building Additions/ Mobile Home Replacements Tax Map #:� Approval Requested for: Applicant � Address: �,�,`Phone #'s: Parcel#: �� � Mobile Home Replacement W`t-�c�SE Building Addition Permit Located: �� Yes No Installation Date: � q� 7 Design flow: �(gpd) Current Contract with Certified Operator on file (if required): �_ Water Supply: � ✓ Well Public or Community Wastewater-system shows no visual evidence of failure on: (date) (Applicant's signature if site visit is not required) ' � � Addition/Replacement Approved Environmental Health pe i ist 11/15/OS 5' �� o Date % North Carolina State Laboratory of Public Health Environmental Sciences Inorganic Chemistry Certificate of Analysis I APR �l ��11 � d�. �O� Box28047-------- 306 N. Wilmington St. Raleigh, NC.27611-8047 htta://siph. ncpublichealth. com Phone: 919-733-7834 Fax: 919-733-8695 � Report To: H. KELLY Name of System: • PERSON CO ENVIRONMENTAL HEALTH LUCIE RED(�iiQ 325 S MORGAN STREET 339 ROBERTSON RD. ROXBORO, NC 27573 Courier # 02-33-15 ROXBORO, NC 27574 EIN: 566000331 EH StarLiMS ID: ES032511-0002001 Date Collected: 03/22/11 Date Received: 03/25/11 Sample Type: Raw Sampling Point: Barn Sample Source: Ground Temp. at Receipt: Sample Description: Comment: Inorganic Chemical I (Profile) Analyte Time Collected: 10:00 AM Collected By: H. Kelly Well Permit #: A027-184 GPS #: Result Allowable Limit Unit Qualifier(s) Arsenic < 0.005 0.010 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Calcium 32 mg/L Chloride 5.80 500 mg/L Chromium < 0.01 0.10 mg/L Copper < 0.05 1.3 mg/L Fluoride 0.21 4.00 mg/L Iron 0.31 0.30 mg/L Lead < 0.005 0.015 mg/L Magnesium 11 mg/L_ , �- ��;�`-,; Y._ ;.^, Manganese 0.27 0.05 mg/L-�-'�� �-� . � pH 7.1 N/A l Selenium < 0.005 0.05 mg/L Silver < 0.05 0.10 mg/L Sodium 9.80 mg/L Sulfate < 5.00 250 mg/L Total Alkalinity 140 mg/L Total Hardness 130 mg/L Zinc 0.10 5.00 mg/L Report Date: 04/06/2011 Page 1 of 1 Reported By: �l�e xuc� . North Carolina State Laboratorv of Public Health 06 N. W?m�ngton St. Environmental Sciences Raleigh, NC 27611-8047 htto://s Iph. state. n c. us Inorganic Chemistry Phone: 919-733-7834 Fax: 919-733-8695 Certificate of Analysis Report To: H. KELLY PERSON CO ENVIRONMENTAL HEALTH 325 S MORGAN STREET ROXBORO, NC 27573 Courier # 02-33-15 StarLiMS ID: ES061610-0055001 Date Collected: 06/14/10 Inorganic ID: Date Re�ei�ed: Oi/16i �0 Sample Type: Sampling Point: At well head tap Sample Source: New Well Temp. at Receipt: 9.0 Sample Description: Comment: Name of System: LUCIE REDMAN 339 ROBERTSON RD. Time Collected: 2:30 PM Collected Sy: H. Kelly Well Permit #: A027-184 GPS #: New Well (Profile) Analyte Result Allowable Limit Unit Qualifier(s) Total Alkalinity 160 mg/L Arsenic < 0.005 0.010 mg/L Copper < 0.05 1.3 mg/L Lead < 0.005 0.015 mg/L Manganese 0.05 0.05 mg/L � - - - Zinc 0.08 5.00 mg/L Barium < 0.1 2.00 mg/L Cadmium < 0.001 0.005 mg/L Chromium < 0.01 0.10 mg/L Silver < 0.05 0.10 mg/L Selenium < 0.005 G.05 mg/L Iron 0.17 0.30 mg/L Mercury < 0.0005 0.002 mg/L Fluoride < 0.20 2.00 mg/L Nitrate < 1.00 10.00 mg/L Nitrite < 0.10 1.00 mg/L Chloride < 5.00 250 mg/L Sulfate < 5.00 250 mg/L pH 8.0 N/A Sodium 9.40 mg/L Calcium 36 mg/L Magnesium 12 mg/L Total Hardness 140 mg/L Report Date: 06/30/2010 Page 1 of 1 Reported By: �e�ic 7%iaKeol r �� � � 1 � � �•. ~`' � � '`f � � � � 1i..L.1 �i.�i.�u �.'Q� �.��.C� � 0.1.+�11 .� �1i. Jl �i <t�i.� tt+� Date: 7 � 3 �l D � T� Map: Parcel: Address: � � Q �06�� � • Re: Bacteriological Water Sample Dear `U�/ � Your well water was sampled on _/ / , and tested by the Person County Health Department for biological contaminants (total coliform and fecal coliform bacteria). The results of your water sample are as follows: � No coliform bacteria were found in your well water and therefore your water can safely be used for drinking, cooking, washing dishes, bathing and showering. Total coliform bacteria were detected in the sample. Fecal coliform bacteria were detected in the sample. Total coliform bacteria are naturally found in the soil and fecal coliform bacteria are associated with animal and/or human waste. The presence of either total or fecal coliform bacteria in well water may indicate that a new or repaired well has not been properly disinfected prior to being used, or that contaminated groundwater is entering the well. The well should be properlv disinfected using the enclosed chlorination procedure. A well contractor or plumber can assist you if rieeded. Once the chlorinated water has been thoroughly flushed out of the system, the Health Department should be notified so that the well can be re-sampled. If the well water continues to test positive for coliform bacteria, then there may be a problem with the water source or with well construction. A well contractor or the Health Department can assist you in identifying the problem and finding a solution. If coliform bacteria are present in your water sample, tlte�Z the water may not, be safe,to use. Young children, the elderly, and individuals with compromised immune systems are especially vulnerable and their physicians should be notified of the results. Water can be disinfected by boilingfor one minute. ' If you need further information please feel free to contact our office at 336-597-1790. We are open weekdays from 8:30 am to 5:00 pm. Sincerely, Environmen Health Specialist Person County Health Department Person County Environmental Health, 325 S. Nlorgan St., Suite C, Roxboro, NC 27573, Phone: 336-597-1790 Revised (11/13/08) � ❑PERSON COUNTY HEALTH DEPARTMENT 355A S. MADISON BLVD. ROXBORO, NC 27573 BACTERIOLOGICAL Wf]TER SAMPLEANALYSIS Name of Owner or Tenant L�� (�1 ��M�43J —�,-- - Address �j�j- 9 �G� n/ � County ��o Collected By �/ ��� Date Collected � Time Collected � .' Z.�} Source: �Yell ❑ Spring ❑ Well Tap ❑ Other �I�To Ch�rge. ❑ Charge R�-s�:.� . x�r�k�k�F�:*�Icxx9c�:xic�r�c9c�t*�'c*�c****�ic9c�F�kx�F�k�k�k9c*�k�t*�k�Y�F�F�k4:�c*dc*�F�c�'c�Fx�k*t�t*�cvkx�r*�k�k�'c�cicnk�c �k�cvk�kiE�'c*9c�ra�:*9:*�c�t�c�c�r*�eaF�F�r*�F*�c�r�t�t9r�:**d:*�:�c****x*9c*ic*�k�kx�k*9c�4a'ca�9c�:9:9:9cx�:�F�c�'c�k**�kd: Total Colifoi-m Fecal/E. Coli. Results Present Absent 0 �J � � � . 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WELL PERMIT (New �Repair� Tax Map: Ab Z7 Parcel: (� �-t� Subdivision: Lot: Applicant's Name: l_U� 1�t�= t�;.�►,�� Mailing Address: 3�� �21�3��2.-T�✓a:� `�D F�/ �Phone Numbers: — �S' Location of Property: Permit Conditions: 1) See attached site plan for proposed well location. 2) All applicable State and County regulations governing construction and setbacks apply. 3) Permits expire 5 years ff-om the date of issue. Other Conditions/Comments: �y��_ �� -�-} �,�L'Tl� ���t� Permit issued by: Date: -- j7`-'� CERTIFICATE OF COMPLETION New Well Inspection: EHS/Da e Location: Grouting: Well Log: Well Tag: Pump Tag: Air Vent: Hose Bib: Casing Height: Concrete Slab: Liner Inspection: EHS/Date Installer: Depth: Grout: Well Abandonment: EHS/Date Completed: Method/Material(s): _ Well Driller: -�A�� License #: Pump Installer: License#: Well Approved by: Date Sample Collected: (o 0 Person County Environmental Health 325 S. Morgan St., Suite C Roxboro, NC 27573 Date: Date Results Mailed: �' Phone: 336-597-1790 Fa�c: 336-597-7808 8/1/08 ��, , �,� � � � � �- '� g,�'`�- I� � �'� �. ��1�I,Y..�..i.._.. 1�' � �,rJ� � � � � � �.�irr�i,roara►.:�rn►,rs���� �"'��r.�H�s� (� � ' ��,,.�., - ���.�...� ��r: �Ve�li Lo� 'G°cation; � �. Tax Iv�P �.� Pn+aef � ��/ Subdivieiur.: Lat * _..�,. � „�, Diatanca Fmm m�ai Pro ��U Co�ec#fon Distusce irom S c 5 ��inr (Miaimwm 1 Q�reat) �' � ��/ `� °P� Ys (Minimw� 60 fcat) . C Tota1 Dcptlti: ���`i ft Yiald: ��{PM 34tic W�r Lavel: � � Watex Heari.aY zon�: Depe� ,�� �} ��� . _ � � f- �R �/�G�`. �."a�aR: !,� .�,�' (�a �� pvG x �+� s {cc.� Itiaptl�: Fe+p� �'i ta �� R. 1?ia�eter• ''� it� '�: t}�u.ra�ixoa st c �� W�ght: 'Ibicl��. 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