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327 Feezor RdAccount #: 990001884 Billed To: Susan Blass Reference Name: Proposed Facility: Residence ATC Number: 2950 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5727-98-5176 Subdivision Info: &2'7 Location/Address: Feezor Road -27028 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER C T UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: V i�i�il S oy 4 &droomr CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 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.�!/a q 14p-oZ J 7 .tw hw-5 r Septic System Installed By: / ft At!i& Environmental Health Specialist's Signature: (/�/_// Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 v (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001884 Tax PIN/EH #: 5727-98-5176 Billed To: Susan Blass Subdivision Info: �3 2-7 Reference Name: Location/Address: Feezor Road -27028 Proposed Facility: Residence Property Size: see map **NOTES* Thi bfr provement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type # #People —'X #Bedrooms #Baths Dishwasher Garbage Disposal; oo'Washing Machine Basement w/Plumbing Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #/Sleats Industrial Waste: ❑ Lot Size Type Water Supply 6 Design Wastewater Flow (GPD) 7 Site: NewerfRepair ❑ System Specifications: Tank Size//M GAL. Pump Tank GAL. Trench Widtho& Rock Depth /j?" Linear Ftg� Other: Required Site Modifrcations/Coi IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** 7 J� k � 3 � Environmental Health Specialist's Signature: Date: 15—,;Il DCHD 05/99 (Revised) • �r . APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ' Davie County Health Department 02020 � 0 Environmental Health Section P.O. Box 848/210 Hospital Street 0 Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROV/IDED. Refer to INFORMATION BULLETIN for instructions.T 1. Name to be Billed Mailing Address .JVD .3an I Q S s (the (1Jo lzena l/atz/contact Person Home Phone .3� �Q^ 1 ✓� �� - S 2 s I-1wA&4E City/State/ZIP -9 Business Phone 7a4 ,!!4a2 -Z7&/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site EvaluationImprovement Permit/ATC ❑ Both 4. System to Service: *7� House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People 3 # Bedrooms # Bathrooms 3 kZ Dishwasher )� Garbage Disposal 4Washing Machine Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes "gNo If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 15� J(..Lc- WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 5-72-7' / B '7� �p� / GJ (JWn 0�r l CJ)10 Ck) U �e e,2- o r- RD.T4s� Day -le- abot,(..� Property Address: Road Name I.C� City/zip oa e - LS v a/r- -2-2029 1 Il 2 m 11e— --T�i-) r i h-`- or) If in a Subdivision provide information, as follows: l -��Zor )01 I S Name: TMd ip�Y Cad Section: Block: Lot: ITat ProP crt1Y Fasgg d `� g -2o- o/ 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Qgie Countrlizalthh Depart t 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. 1 DATE O t SIGNATURE `\'CYVI�CGI�/QQ� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. D Invoice No. T } N COO* SVP AT THIS TIME. (;�I 6 wl«L . ii IIiE C�I_SC RPI4)rl I2L•-.,<<J,D 1 J 8. 169. FC. 86ii. UNE BEARING DISTANCE LB S B2745'55: E 28.18 L9 S 7730:18. E 68.88 le EDEA G. 851 R'w98PQ 27.094 AC. AS SL TUTTEROW SURVE AUGUST -31—' / SPKE NG ISTANC A W W A } N COO* SVP AT THIS TIME. (;�I 6 wl«L . ii IIiE C�I_SC RPI4)rl I2L•-.,<<J,D 1 J 8. 169. FC. 86ii. UNE BEARING DISTANCE LB S B2745'55: E 28.18 L9 S 7730:18. E 68.88 le EDEA G. 851 R'w98PQ 27.094 AC. AS SL TUTTEROW SURVE AUGUST -31—' / SPKE NG ISTANC ...: %-uuuty riealtlt Department 'G Env/tvnafental /fealth Suction U {� P.O. Box 818/210 Hospital Street S�"Mockaville, NC 270211 AM 15 p' U Pte" 13361751-6760 . . . , 'r ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED 9NLE88 ALL THEQU;P-2-3VIC N INFORMATION IS PPJMDED. Refer to th/ef INFORMATION BULLETIN for instructions. 1. Maas to be Billed 0 }tea I ! Contact Qsrsottl(�� Mailing Address dE�A/' /i -Na �y Sam phone & y��l- e�fo/ g City/state/zIr _ Nl be � ill Il L�-, ! V � "f Q Business Phone o+ r0 / o 2. Macs on Permit/ATC It Ditterent than Umme Mailing Address City/state/zip z. Application Tor: ( Site Evaluation 0 Inpraveaaent permit/ATC 0 Both e. aystes, to service: House 0 Mobile Home 0 Business 0 Industry a. it Residence: i People it Beoams A Dishwasher U Oatbage Disposal A Nashing Machine ne 6. it Susisel2ndustty/Other: tapeeity tn* # comodes dr O other 9 Bathrooma� I�-- U Easement/Plumbing U Sasexant/no Pluabing 1 People i Unks f shovers 11 urinals i Nater Coolers Ii' FOODSERVICE: i Seats Estimated Water Usage lgaiions per day) 7. Typo of water supply: County/City O well 0 Coummity s. Do you anticipate additions or expansions of the facility this system Is intended to Servet 0 Yes 0 No If yes, what type! `1 *1MPORTANT"'* CLIENTS 11fUST CVAMLEtE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. /�Either a PLAT ar SITE U PLAN MHE,S�jUBhilIM b flu client with THIS APPLICATION. Property Dimensions R eS(3'0 a / / �% Dl1tKC IONS ([ram Modovllle) to PROPERTY: Tax OtticePIN: # &7�-- Property Address: Road Name Fe -&Z-0 %� I� � - &- 1`r/ C O C]L . ��- U City/Zip �60Cy.til i� C_ Com-.. 0 Yr - - - Ii In a Subdivision provide information, as follows: Name: Section: Block: l et:'Date rly Flagged: _ � —,50 Yt� ��-1S�j t-/" E. This is to certify that the information provided Is correct to the best of my knowledge. I bndea•atasd a any- permits) Issued bere:afier are subject to suspension or revocation, if the site plans or Intended use change, or if the iarormatlon submitted in this application is falsified orchanged. I, afro, undnstand that I am reronsible for alt climes incurred front this gWUcadon. i, hereby, give consent to the Authorized Representative of the Davie County 13 all b,Depa meat �� t to enter upon above described property located in Davie County and owned by (,(0}77'2 LA to conduct all otesting procedures as necessary to determine the site sultabiif . DATE �7' I-� ' �� SIGNATURE �.� (/L �' )&C&- THiS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Intrude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account Na 4�'_____ Revised DCHD,(07/98) Invoice No. CP /43 Pl. nl j I? , T, ............ '52 ............ 9 3 2� 2 2?.G n a. to � vl� Av �78 ('28. 44— jA� too I Uj �00.58 54 — 3441 22, 1 kid QLD 08 4.3? 6 2 G I:? r—T *f3 P- 4 0`n681.121 7— OJ co iAc I P//V I - �03 t. 5Ac 01 --A V)"z 53 'A ID V) N 50-Z) C4 7 8.4 c -All_1 7 -el 6 p- 350 0 : 51-02 ir C, C-) 6.8 6 4 Ac 4-5 223 p 287 93 v, juz_4_z__ ,crl7:2'7_ Z _lAA1 .6 29 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME _ l DATE EVALUATED '7 /vs ?,/I q PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public L1___ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH g Texture group Consistence Structure Mineralogy HORIZON II DEPTH G " Texture group Consistence Structure 19b V 14' Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:{� C'�F ✓(J LONG-TERM ACCEPTANCE RATE: i d� REMARKS: �ue'rS`! /li0 , 4,/ LEGEND DCHD (01-90) Landscane Position EVALUATION BY: OTHER(S) PRESENT: 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet 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 Notes 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 DAME COUNTY HEALTH DEPARTMENT ENVIRONMENTAL. HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 Apri130, 1999 Wyonna Dull 292 Feezor Road Mocksville, NC 27028 Re: Site Evaluation/Feezor Road -Site 1 Tax Office PIN: #5727-88-8116 Dear Client(s): As requested, a representative from this office visited the aforementioned site on April 28, 1999. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd Enclosure(s) .. , % mus t Ueparhnent �� Envftonmentot Health shtwon ' P.O. Box 848/210 Hospital Street Mockaville, INC 21028 1336) 751-8760 9 A A r APR 15 W9 ***IHPORTMn'*** tHIS APPLICATION CWWr AE PROCESSED UNLESS ALL THE cot., N XNti' MTICH IS PROVIDED. Refer to the INE'ORMATIOH BULLETIN for instructions. nave to be Billed Nailing Address City/state/sip nave on perfait/ASC It Different than Above Wailing Address Contact Person Business Phone city/state/Lip 77a- L'z(l Applioation for: ,Site Evaluation 0 Improvement permit/ATC 0 Both System to service: House 0 Mobile Home 0 Business 0 Industry 0 Other It Residence: A People 5 _ It Bedrooms .5 t Bathrooms A Dishwasher 0 Oarbage Disposal flashing Machine 0 Basement/plumbing 0 Basement/No Pluabing It Business/Industry/other: specify type I coanodes t showers I Urinals 4 People I sinks # Nater Coolers If FOODSEHVICB: 1 Seats �! Retimated Nater Usage (gallons per day) 7. Type of water supply: County/City 0 Well 0 Comounity a. Do you anticipate additions or expansions of 16e facility this system Is intended to serve! 0 Yes 0 No U yes, what type' L*1%*1HP0firAN1%** CLIENTS AfuncuAIPL mmE IMVUtRED PROPERTY INFORMATION REQUESTED ELOW. Either a PLAT or SITE PLAN AwsryBESt/BM TTED by Medical with TM APPLICATION. Property Dimensions: -6 R cp- WRITK DIRECTIONS (from Mocbville) to PROPERTY: Tax Ottke PIN: #VL Proper(. Address: Road Name FPe'ZO ��'"I C O �, �"- U City/Zip V/ d�. j�S 1/ •! I �. I Y C-'_C;�. 0 Y JtC-4- past If in a Subdivision provide information, as follows: (�S �A ha4(�(a- Name: EM, Section: Block: _ �L�- Date rly Flagged: C�be-IG r -e- �0 l ei%-hamIn j 1 This is to certify that the Information provided is correct to the best or my knowledge, derstand a any permits) Issued bertsMer are subject to suspension or revocation, if the site plans or Intended use change, or It the inrormatlon submitted In this application is falsified or changed 1, also, anAnwand that t ant nVonsibte for ail charges Incurred f mrr this appUcadon. 1, hereby, give consent to the Authorized Representative of the Davie County 8 lb epailment Q / to enter upon above described property located In Davie County and owned by /5 / CC,Gt 0y1 Ti fJ i to conduct all testing procedure as necessary to determine the site D/lTL �'ISIGNATU!19sultabill ,91 % GL- X9, THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (fact -ode all of lbe following: Existing and proposed property lines and dimenstons, structures, setbacks, and septic locations), Account No. Revised DCHD (07/98) Invoice Na Iff I I 3 00 V, r,. 0 , p cp. tp i . c 4 JACK,' r3R. • =�. � ,,. � � �-� � � ate' ,<.lP , <. 3.7857 . ' .. :41 r f. (28.4Ac� 76 10000.581 Sq r.'.•' e� '� �eC?' t !G 22308 43 Lo it%�'r. a Y ty` �• 2 f-: Q V'I J ,k �- IAc �N� � ' jC/. Y• m l7 r 103 n`"77-77-�Q� 5 AC V ao 53 1i rn cn m — m ' `°w1 23.15AcV— G t 5 �? 0 ,n a1 ° v pC * •� p� a a' t1 . J iL � :J `r 15. y o, 7 8Ac . Q r Jr Fr + N \ (vim ', 6 Z Q C kj 350" m RO In : 51.02 E,i-(� 400 _ 6 O y N iy .84 Arc a 223 N�xISY" 4. 5 AC 897 IAC 297IAC DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME` PROPOSED FACILITY SUBDIVISION Water Supply Evaluation By: On -Site Well Community Auger Boring Pit DATE EVALUATED PROPERTY SIZE J �� ROAD NAME Public 1.1� Cut FACTORS 1 2 3 4 5 6 7 Landscape position G— .GL Sloe % G HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture ffoup Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: . REMARKS: DCHD (O1-90) LEGEND Landscape Position EVALUATION BY: OTHER(S) PRESENT: 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet 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 Notes 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 on ME ME No ON i ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■Eli%\i■■■�■■■■■■■■ ■■lir'■■■■■■■■■■■■■ii ■■■M■■■■■■■■■n■iii ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ iii mom MEN MEN ■■ME■■ME■ ■MEMO■■■■ ■M■MMM■M■ ■■■MOM■■■ ■■■■MEM■■ ■E■MEME■■ ■E■■■■M■■ ■■E■■■■■■ ■MME■■■■■ ■E■OM■■■■ ■■■MME■■■ ■■MEM■■■■ ■EM■■■■■■ ■E■■E■■E■ ■M■■ME■■■ ■■EEE■■■■ ■■■■■■■E■ IMEMEMEEMMONS mommmal MOEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ I■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■NEON ■■■■■■■■■■■■■ ■ MEN ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■