232 Jamestowne Dr ermiClee'sL)ZC r 064� ��GD�,NIE COUNTY HEALTH DEPARTMENT
Name:' Environmental Health Section PROPERTY INFORMATION
_. .� eta P.O. Box 848
Directions to property:_ 1�� `` Mocksville,NC 27028 Subdivision Name:
""✓ 10641�� G� J4#%;iaG ,N1t Phone#:336-751-8760
Section:
AUTHORIZATION FOR
WASTEWATER Tax Of ' PIN:#
SYSTEM CONSTRUCTION - 7tii
AUTHORIZATION NO: 0 2 A Rad Name: == -1 t
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Da ' ealth Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article-1 of G.S.Chaapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
Iv ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
LEN�iROA
I��G IS VALID FOR A PERIOD OF FIVE YEARS.
M TH CI
DATEISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE r #BEDROOMS ' #BATHS '`— #OCCUPANTS�_GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFTV42)
EATS INDUSTRIAL WASTE:Yes or No
ACRE -
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) EW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WROCK DEPTH LINEAR FT.OTHERv I I OBJ
REQUIRED SITE MODIFICATIONS/CONDITIONS: }
IMPROVEMENT PERMIT LAYOUT
As stinted in 15A NCAC 18A.1969(5)
accepted Systems may also be used
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DMD 02/02(Revised) N�O 1�G 11/7✓
DA IE COUNTY HEALTH DEPARTMENT
dame:— Environmental Health Section PROPERTY INFORMATION
• `tet _ - t J�' i P.O. Box 848
DlrectlCris "property. �" 7th #.P„ i e t� ` Mocksville,NC 27028 Subdivision Name:
Phone#: 336-751-8760
Section:
AUTHORIZATION FOR
"µ WASTEWATER Tax Of PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION`NO: 002713 A Rad Name " - '1'� �"'` p
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Da o�nvironmmM-14ealth Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County,Building Inspections
` Office when applying for Building Permits. ,
(In compliance with Articled l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION POR WASTEWATER CONSTRUCTION
;` :'rL-- �, i`A/. ✓ IS VALID FOR A PERIOD OF FIVE YEARS.
�,.-ENVI-i Aim-HEX TH S,FCIAL1ST; DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS �3 #BATHS #OCCUPANTS `GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY 4L DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
�tp '/LL
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMPTANK t/GAL. TRENCH WI T ROCK DEPTH LINEAR FT.
OTHER L.- t-TN4�wf 1NL7 �:.LrLAAJ H/q..VI: ; l t/1 IC)�j F
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1-i `" �L' N3 ALL-
IMPROVEMENT PERMIT LAYOUT
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
' SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT D DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02(Revised)
` j
. �� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION1Jg-�d• $�
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) 919'q
NAMEUlf re(1 /�� �� PHONE NUMBER
ADDRESS L32 �VM46 jj Dal' 0 /r✓Io hVifleSUBDIVISION NAME
/�`f r / �J/ / " / L,O�T�#
DIRECTIONS TO SITE b`7' EAST !�'�7'T 0&/D e4f1y t7Z &k • DffsS 1;_rC11dV1
ml
/-51 houses o �e. cur��. Amuae
DATE SYSTEM INSTALLED z NAME SYSTEM INSTALLED UNDER N-4
TYPE FACILITYjjjl�Wa PUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PR LEM OCCURRING bokleti
w ?
DATE REQUESTED 11-7-Z-0160 INFORMATION TAKEN BY '
This is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
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DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Water Supply: On-Site Well' Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 1.
Slope% Lj 7_0 n
HORIZON I DEPTH ' QaO
Texture group Se-L �-L—
Consistence S
Structure
MineralogyS Sv
HORIZON H DEPTH - 7 I
Texture group 4 L
Consistence Fr
Structure 4.
Mineralogy 1 > 5.-
HORIZON III DEPTH 20- 1 b- O
Texture groupGjL
Consistence SS
Structure
Mineralogy '
HORIZON IV DEPTH ZIO—
Texture group _JA L
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON f& D d
SAPROLITE S
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE i
- c� n
SITE CLASSIFICATION: d EVALUATION BY: t-f
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: f� S' 1 GA Sg� f 0Z_(M,t�IV'-& )
LEGEND 'Landscape Position
R-Ridge , S -Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
41St -
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
NS -Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
lYQtes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised)
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-7-c 3
;Permittee . DAVI COUNTI'HEALTH DEPARTMENT
Named ,fJr r'' . .j '.. "f'. ° _ 'r;-Epvironmental Health Section PROPERTY INFORMATION
_.
P.O. Box 848 :'`/ O S,
Directions to property: Mocksville.NC 27028 Subdivision Name: b l/�
one#.336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
�Tt�-
AUTHORIZATION NO: 2519 A Road Name: Zip: 2 70 zp'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In com liance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�t; /( ✓';; 1 s :� /�'�: IS VALID FOR A PERIOD OF FIVE YEARS..
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS "X #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
'COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH=\ ROCK DEPTH ld LINEAR FT.
OTHER -
foeREQUIRED SITE MODIFICATIONS CONDIT ONS:
IMPROVEMENT PERMIT LAYOUT.
-- Ive&'
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-'9:30 A.M.OR 1;00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTEMI ED BY:
.Prow- h�SG-$Tlu��,
s• � New �� "h�n
c.
Ire
AUTHORIZATION NO. Zs19 �} OPERATION PERMIT BY: DATE: �-2 7" d
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
ncao ovoz(Revised)
C �J ���
1 e itmit e �� ,,:,DAVIE COUNT t HEALTH DEPARTMENT
'Environmental Health Section PROPERTY INFORMATION
• vklz P.O.Box 848
-Directions to property:
Subdivision Name:
,
hone, :."•336-751=8760
�:�'� i+, �' ,r' :/"• `,� .A�� -.j✓'r"'" '�4��•.,w"'f <' rSection: Lot:
f. AUTHORIZATION FOR
WASTEWATER Tax Office PN� -
SYSTEM CONSTRUCTION -
AiJTHORIZATION N.O. ' . , , A Road Name.
V. Zip: 7 7e)2�'
**NOTE*.*,This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County.Environmental Health Section prior
to issuance.of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.'
(In compliance with Article l I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r
�; �, %. "� r,✓ ' �� `,, IS VALID FOR PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED .
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY r '/t.DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH rr! 'r ROCK DEPTH LINEAR FT.
f
REQUIRED SITE MODIFICATION$/CONDI ONS: :).' '•j� �f! l(i7�
IFI {�(i Y II J:!` \; �, il
IMPROVEMENT PERMIT LAYOUT s s Fr 4
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTEM ED BY:
' .. Off\ . ��9�H WQ/L �('^N nn�•�•i1
t�
SA � i Nr rsC. •' !'
�a
r � •
AUTHORIZATION NO. 2 s OPERATION PBRMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEM",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DMD OM(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ��/� G1Sh- a- PHONE NUMBER 7
ADDRESS ��c��.� //�/UF �i �1�s'f �i� SUBDIVISION NAME
��`c'�S✓. //� =G` LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED2A2NAME SYSTEM INSTALLED UNDER r u
TYPE FACILITY 06/- NUMBER BEDROOMS NUMBER PEOPLE SERVED T
TYPE WATER SUPPLY r1f SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge.and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT if
Rev.1193
�t:—.^t .f sQ'C.. ,..1r• /� r /�..— 'Z�--'�
• / rnu=A (
AVIE COUNTY HEALTH DEPARTMENT F fName •y Environmental Health SectionP.O.Box 848
Directions to' roperty: f� . �` �" �i i7�/I cksville,NC 27028 Subdivision Name:
Phone#: 336-751-8760
Section: Lot:
;...• AUTHORIZATION FOR
WASTEWATER f
n+ Tax �cePIN.:-#
SYSTEM CONSTRUCTIONO`J AJ424
AUTHORIZATION NO: A Fpad Name;)L3 S'
i� Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davieountv`,'Eai timental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
f1 / ti
� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
A&h19f
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE '#BEDROOMS ly #BATHS .+ #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
r
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE !�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH"~ROCK DEPTH y LINEAR FT. J v
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT N
`, l 9
to,'A �1 1
r4s� nab
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTM &16NTEILEPHONE#IS
INAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-'9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTAL (336)751-8760.
fjD
OPERATION PERMIT ��./ '�
!•�' LED BY (:ar4,
:Ad i0o �.1
s�hvwr�
AUTHORIZATION N� OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0=(Revised) ^
73
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& t5
Davie County Health Department
Environmental Health section OCT 13
P.O. Box 848/210 Hospital Street ���4
Mocksville, NC 27028
(336)751-8760
DAV7E
336)751-8760Q4VIE
COU
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed P. h o.Ne- 1.• /OG'ro Contact PersonZ9—c
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Mailing Address J 3r 5— /` vf�l 4 C re �. Home Pkg
City/State/ZIP /��„� tr �/' A/C Z$079 Business Phone 7 o N g o Z- t VJ
2. Name on Permit/ATC if Different than Above Lgilry
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: R Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms r' 3 # Bathrooms Z
oNDishwasher []Garbage Disposal XWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes- # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
S. Type of water supply: ❑ County/City '19 Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Qg No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: I &e t'*+ Mo% X Z�C WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: k #S 7 S I-Ir 0-3 8 -11 +F S ` CrA, c T-
-)--32-
Property
--32Property Address: Road Nartle ��+-��T�a,.1,. D,r 1- • �a+^'�R-S��v� i A►a
City/Zip N'tod<t✓,l(e—
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date home corners flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understand that I ant responsible for all charges incurred from
this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE / O o �L SIGNATURE
THIS AREA MAY BE USED FOR DRA G_*UR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, Wicks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
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Sign given Account No. 3
Revised DCHD(05/03 Invoice No. 3
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