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HomeMy WebLinkAbout1230 SANTUIT-NEWTOWN ROAD - Health 123 NEWTOWN RW COTUIT�� W +` A = Ok 637 80a- - - - - -- --- - - - - 4 I�h i �i f I TOWN OF BARNSTABLE LOCATION WUJVQVJ" C1 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT o 'Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY \S 00 9P k k o LEACHING FACILITY: (type) c� Q T—C (size) 'dL t 10K!9 NO.OF BEDROOMS BUILDER OR OWNER \Rul R Aj< v PERMITDATE:�31 V 2� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to th VZ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet"�of�lleachin facility) � �• Feet Furnished by �/11 C/ �-t� COJI�IO\t'�'E.kLTH OF LASSACHUSETTS - .:-. EXECUTIVE OFFICE OF E\��IROti14E\T.�L AFFAIRS DEPARTMENT OF ENviRoNNIENTAL PROTECTION ONE '%%INTER STP.rL7. BOS ON �L� 021(IF (61 292-:i50v TRUDY CORE Secre:an ARGEO PAUL CELLUCCI DAVID B. STRU-r.S Governor Comrrussic::er Governor ti�b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `✓ PART A �b 1 OUL CERTIFICATION tJ`� i 1 - Property Address: \Z3 �C \ ^' �' Name of Owner W� Lt�'V•l Address of Owner: 5{}�.' Date of Inspection: � `//u� , // Name of Inspector:(Please Pri ) •c4 a P l F CC- O I am a DEP approved system inspector pursuant to Section 15.(340 of Title 5(310 CMR 15.000)' Company Name: g& r'c Etc Lr'rL��_ra C �. It cA F Mailing Address: ., ;�4- N 14<Nft= I1 �Z6It Telephone Number: 4SQ-Z L-44 /[t • �o CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation B t cal Approving Authority _jl Inspector's Signatur Date: 3 1 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS o' �e 4 APR d 8 1999 c, revised 9/2/98 Page Iof11 V,i Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) %roperty Address: 2,73 Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y. N, or NO). Describe basis of determination in all instances. If "not determined", explain why nct. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)•indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CM 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. i 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC/ANDSAFE-TY PLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption syste (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption sy em and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption s stem and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption ystem and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water alysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility a the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine dist nce (approximation not valid). 3) OTHER t revised 9/ /98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following I have determined that one or more of the following failure conditions exist as described in 310 C R 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what ill be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or clo ad SAS or cesspool. Discharge or ponding of effluent to the surface cf the ground or surface water due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an over oaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6' below invert or available volum is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clod or obstructed pipelsl. Number of times pumped_. _ Any portion of the Soil Absorption System, cesspool or privy is elow the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a sur ace water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a ublic well. _ Any portion of a cesspool or privy is within 50 feet of private water supply well. Any portion of a cesspool or privy is less-than 100 eat but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well ha been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, mmonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the foll ing: The following criteria apply to large systems in dition to the criteria above: The system serves a facility with a design fl of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment be se one or more of the following conditions exist: Yes No the system is within 400 fe of a surface drinking water supply the system is within 200 eet of a tributary to a surface drinking water supply the system is located' a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone [[ of a public water supply well), The owner or operator of any such sy`tern shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further' formation. revised 9/2/ 8 Page aoru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: `Z JG NwJT�v�fJ Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes- or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N;A. The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. x _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) The facility owner(and occupants,if different from owner) were provided with information on the propermaintanaaco.of SubSurface Disposal Systems. L revised 9/2/98 Page Softt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION $roperty Address:�ZTjO r�tw�a-*J 13 Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:5SQ g.p•d./bedroom. Number of bedrooms (design):_ Number of bedrooms (actual): Total DESIGN flowSSo Number of current residents: Garbage grinder(yes or no):,� Laundry(separate system) 01or©o to If yes, separate inspection required Laundry system inspected es r no) Seasonal use (yes or no): iJ Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): 'J _ Lest date of occupancy: sea COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: 9pd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ ' Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Lest date of occupancy: OTHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool " Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) s 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other r T, O`cY" Ni••+'f aU a ii. APPROXIMATE AGE of all components, date installed(if known) and source of information: y : Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) koperty Address: 1236 Owner': Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction:_cast iron x40 PVC other (explain), Distance from private water supply well or suction line Diameter _ Comments: (condition of joints, venting, evidence of leakage,etc.) t SEPTIC TANK: S (locate on site pIhn) I Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: �StU�lA Sludge depth: Z—" - Distance from top of sludge to bottom of outlet tee or baffle: �2�1 Scum thickness: O" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: (y How dimensions were determined: c) 'omments: (recommendation for pumping,condition of inle�and outlet tees or baffles, depth of liquid level i;relation to outlet invert structural integrity, , evi ence of eaka e,etc.) JZ1' GREASE TRAP:_. (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7orti f _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 50 Owner: Date of Inspection: TIGHT OR HOLDING TANK: � (Tank must belpumped prior to, or at t^e of;inspection) � (locate on site plan) Depth below grade:_ , other(explain) Material of construction:_concrete _metal_Fiberglass_Polyethyler_ _ Dimensions: Capacity: gallons Design flow: gallons:day Alarm present Alarm level: Alarm in working order: Yes= No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float,switches, etc.) DISTRIBUTION BOX: (locate on site plan) �� + Depth of liquid level above outlet invert: Comments: - 1 ote it level an distrib lion is eq al, evidence of solids carryover, vide'ce of leakagg into or out of box,'etc.) r 1Jp Sal l dE `�- PUMP CHAMBER:1.0 (locate on site plan) Pumps in working order:(Yes or No) a F z Alarms in working order(Yes or No) Comments: k (note condition of pump chamber,•condition of pumps and appurtenances; etc.) „ revised 9/2/98 pages oral SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 4operty Address: %'W Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): 5 (locate on site plan, if possible; excavation not required. location may be approximated by non-intrusive methods) If not locate. explain: Type: leaching pits, number:�L2k� leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetatio , etc. 1 L N O•— 0-' t t\ CESSPOOLS:t (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r PRIVY:�r�0 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note contrition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1� 2 S U a I - 4j1 Wks 50 PAS 3S 5s- S, revised 9/2/98 Page 10of11 A • 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: , Owner: Date of Inspection: NRCS Report name - — -- — Soil Type_ -- ----- Typical depth to groundwater USGS Date website visited 1 Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope k*,Ls _ Surface water t' \c u' ;w•-y roc�- J S Check Cellar'�>tL.-A Shallow wells I-Aw.', Estimated Depth to Groundwater S IZFeet ' Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record XObserved Site(Abutting property, observation hole, basement sump etc.) �Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) j revised 9/2/98 Page I,I of l,t No....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............��O........OF..... .................................. Appliration for Dispas,41 W,ark, Tonotrurtion thrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at:. .................. ...... U3..... ................... ...a...........--------------------................. _. .. 'on S)ts or Lot No. V" -------- .................................................................................................. ........... Chad ..misl . .................. Owner Address G .................................... .................................................................................................. 14 ................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..............4..........................Expansion Attic Garbage Grinder ( P4 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria ( 04 Other fixtures ....................................................................... ................................................................................ Design Flow.................::-Z_................_._.gallons-per person per day. Total daily flow.......I.q4.2.........................gallons. 1:4 Septic Tank—Liquid capacity._. !!..gallons Length..1o.'L". Widih...&AK. ­ Diameter________________ Depth..!S.. ..... Disposal Trench—No. ...... Width.............. Total Length..................... Total leaching area....................sq. f t. Seepage Pit No.......Z---------- Diameter......i.Q-1........ Depth below inlet....(2 ........... Total leaching Z Other Distribution box ( K Dosing tank ( ) - Percolation Test Results Performed by... ................................. Date_._._4 ............... al Test Pit No. 1...4 ...minutes per inch Depth of Test Pit.A4!! ........ Depth to ground water. Test Pit No. 2_4ef�:L...minutes per inch Depth of Test ......... Depth to ground water./V ---------------------I .................................................................................................................................. 0 Description of Soil.............. . ................................................................................................................................ W ------------------------------------------------------ ------- --------------------------------------------------- ---------*......*............ .............................................................................................................................................................................................7.......... U Nature of Repairs or Alterations—Answer when applicable--------....................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I Ti 1E 5 of the State Sanitary Code—The undersigned further agrees not to ph in operation until a Certificate of Compliance has beep issued by t oar of i Ith. Sign --- ------------- ------------ Signe ...................4---7--- Date ApplicationApproved By................... .. .......... ....... . ...................................... -­-­­3. e__ )--Date Application Disapproved for the follo 'ng reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_...................................................... Date Nip No.... ................... Fim, ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --d If Irt ........ ....................OF.......r j ............................................................................. Appliration for Uhipvl*J Works"),Taftstrurtion "pamit Application is heieby made for a Permit to C,,. S;j tuct or Repair an Individual Sewage Disposal System at: Ut D ............i.m.— ................................................................................................... Location rAddress or Lot No. ..........�at, I ,� - .................................... .........................................................................----------------------- Owner Address f4 TA ............... .................................. . ......... 1.4 Installer Address Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms....................__...........____.._..Expansion Attic Garbage Grinder Other—Type of Building 1�........................... No. of,persons............................ Showers Cafeteria Otherfixtures .........................................................................................................I............................................. Design Flow.................. ...........!`.....gallons per person per day. T6tal daily flow..._.._!q4q.........................gallons. Septic Tank—Liquid capacitv.!5�?O'.gallons LengthJ Widih.'S..!�-'_ Diameter------------:--- Depth..CZ, .............. bisposal Trench No..:��.......Width-JA............. Total Length.._....._...._...:_. Total leaching area....................sq. f t. �T Seepage Pit No....._.?—....._..._.. Diameter.....!;:�'......... Depth below inlet...j6nt............ Total leaching area.!!:?9% sq:tftX� ,Zz Other Distribution box ( K Dosing tank ( ) —1, Percolation Test,Results Performed by---W_�44..-.0f.j.�C1........................ .... Date...... ..... ... . ......... ...... .... ....... .... ..................... Test Pit No. 1...4Z---minutes per inch *Depth of Test Depth to ground water'44 Test Pit No. 2...�---minutes per 'inch Depth of Test Pit..14A�..... Depth to ground watedvqv ....................... ----------------- ------------------------------------------------------------------------------------ ----------------- ......... ......................................................................... 0 Description of Soil................ --------------------- ............... ......................................................................................-I................................................I.................................................................... ........................................ ....... ............................................................................................ --------------------------------------------------------- Nature of Repairs or Alterations—Answer whet! applicable._....... ..................................................................... .................................................................................................................. ..................................................................................... Agreement: The undersigned agrees to install the afor6described Individual Sewage Disposal'Systm'in accordance with the provisions of TITIZ 5 of the State Sanitary Code—The undersigned further agr6es not to.pl• -.system in operation until a Certificate of Compliance has beep ussued by t oar of lth. Sig ... - ­ ----------- ate .. . ................... ............. . .........Application Approved By-------------------- I ..... .... . T Date Application Disapproved for the follo ng reasons:---------------------------------4............I--------.......................... ----------------- ....................................................................................................................................................... ............................................... Date Permit No. Issued_------_ - _.- ..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................... OF... .. A; `i........................ (IrrIffiratr of Tomb haurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed, or lRepaired by............................ .......................................................................................................................... <7 Installer at ---­---------------­----:........... ..........................L ...... ............I........ has been installed in accordance with the provisions of T.1 T JE 5 of The State Sanitary Code as described in the dated_,_—_>—/1---q-b?.......e!*:�' application for Disposal Works Construction Permit No. ...... .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............791hffo Inspector_��M .................................................I............. ..........****------------- .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OG OF._ ............................................. FE N .......................................... ................... Disposal Works Tvastrudion "Jinutit Permission is hereby granted..............0 .... ............................................................................... to Construct (-/) or Repair ( ) an Individual Sewage Dispg!ial System C)LD W1 at ......—I,.........S.-A.-VIAq- ........t -1--------K,........I.............. Street as shown on the application for Disposal Works Construction Permit No_'�6:7>�&atacd........ �_. �:�j.�� .......................................... A ................ .................... 1A)a d of Ifealth D. . . ........ .................... DATE.... . . . .�,.-_...__.�........-----..-.... ..-.....-....-.. ......,,.._..•._.,,_..__..,....,..._.._...,.. ...w...... ..,. £�.....,,..,..-.....r_.._�...�._.... ` -...-..... -...�. ... .,-,»......,...-,.,....-......,...,,..»...�...._.�._......_..,......... --- ...,., _..�.�._.. BEST 1-f0 j ilia - 4 _.__ _w %S D i o - a bo94 s 1'� 34. 4.00 3 ? 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