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HomeMy WebLinkAbout25-28S/^6s-oo5^j ^\ Department of Safety [^ & ProfessjiQnaJL,Sgfv,i,c( Industry S|e?»giNAY i 3 2025 County ^ C..Y -^. ~e I Sanitary Permit Number (to be filled in by Co.)'^- ^83 Sanitary Permit Applicatidri State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to tliEsom!B8BPti8<goi is required prior to obtaining a sanitaiy permit. Note: Application forms for state-iftWACRWfSafc'' the Department of Safety and Professional Services, Personal information you provide may be used for secondaiy puiposes in accordance with the Privacy Law, s, 15.04(l)(m), Stats, I. Application Information - Please Print All Information Project Address (if different than mailing address) 9^9 <-~^' (^^— Lei k£ ?f; Property Owner's Name 'T/Wl S7-& 4'^-e .1 Parcel#•ttT^-fcTA> ^^4ifl<- Property Owner's Mailing Address ^°3 5-/ 6 ^'&'^ "i ^ City, State^-f-l-i B ^ ^ ^ ^ ^i ^Zip Code s~<ros% II. Type of Building (check all that apply) IjS 1 of 2 Family Dwelling - Number of Bedrooms d Public/Commercial - Describe Use D State Owned - Describe Use •^- Property Location Oovt. Lot.Phone Number ^iz. --^f o-^3^_'/4,..%, Section 1-7 Lot H L^"7N R X _XbC® Subdivision Name BlocUT ^/-^^/oo.i L^k.^ T-st^ CSM Number a City of. D Village of Sa Town of, "^-^ t_^ ?- • ^"^^ III. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C if| applicable.) A,^ New System D Replacement System D Other Modification to Existing System (explain)D Additional Pretreatment Unit (explain) B.D Holding Tank S In.Oround (conventional) a At-Orade D Mound a Individual Site Design a Other Type (explain) c.D Renewal Before Expiration D Revision D Change of Plumber D Transfer to New OwnerlIList Previous Permit Number and Date Issued IV. DispersaI/Treatment Area and Tank Information: Design Flow (gpd)30 o Design Soil Application Ratc(gpd/sf) .7 Dispersal Area Required (sf)^25 Dispersal Area Proposed (sf)'^ t/^~System Elevation <s> >n Tank Information Capacity in Gallons New Tanks Existing Tanks Total Gallons # of Units -r Manufacturer 8 &8 •oiZ 0 Septit; ui-H»l<iing Tank -7 $-0 -y^~o UJis.'e.s'e.x C.c'^C..<^ Boiling Cteniiter V. Responsibility Statement- I, the undersigned, assume responsibility for installgtion oftIiePOWTS shown on the attached plans. Plumber's Name (Print) 1<^ T^ ^ ^-^s k-i •WP/MPRS Number 2.2. ^oc; 0 Business Phone Number '7^S~ ^-^-^ ' IS~(ft Plumber's Address (Street, City, State, Zip Code) _ .,Ka B^ .s-2-z- ' ^^^^^^^"L ^^7 VI. County/Department Use Only Approved a Disapproved a Owner Given Reason for Denial Permit Fee $ zf00 , o^ Date Issued 5^/25^it Sienatm /i/2'?7/3 ^y Conditions ofApprovaI/Reasons for Disapproval <^e^ aJ^^A^C ^^'<^. / Attach to complete plans for the system and submit to the County only on paper not less thnn 81/2x11 Inches In si/.c SBD-6398 (R. 03/22) May. 5, 2017 10:41AM BAYFIELO CO PLANNING & In-Ground Gravity Plan Index & Cover Sheet Component Manual Design RefGrences: Version 2.0, SBD-10705-P(N.01/01, R. 10/12) 3,9.975 P. 3 PAGE 1 OF 7 Pg1of7 Pg 2 of 7 Pg 3 of-7 Pg 4 of 7 Index & Cover Sheet Plot Plan Sefh<-'T^n^ c-f-€^ Section & Plan View Management Pian Attachments: 6? ^r£?f T^1_ '^ ^ •:>^ -7 :nclosures: POWTS Application for Review < ^^.-{-a ^ p&rm.+ ^F?) Soil Evaluation Report & Site Map ^l&.< <t4 •€-*•<. ^ M c^z- ^ ^ «e -£ '*<-£ ->if-SBW ^ Project Name / Description MAY132Q25 j3gyfiffl|ri nn Znnina Dept. Owner Name(s):T/ ^\ S U^-^^Owner Nam®(s).j ' ^\ -? / €.T i e-'^> _ Phona: ^/Z- -Z-)s£> - Owner Address: 7 S ^ ^ ^TCv-^^^^^r^'S ,-.< ^/y/O'Zjp: ^S~^^I. Project Address: ^ z ^^ ^ / ^^ *-> 2^r ^e A ^ [^ VA co^ Lftfce ^^-cA &5 '1-^ rf^ *». Township: '"^y^^ '^ - '"^.r 9 <-i ^. t u -e_ (^ l-\-' ^ -s"^ l~t y y 7 Section /-7 . T ¥7 N-R S _ ELJor W . County: Brt^^'-e / Project Parcel ID #: 'P^^c-^f -LDCt3^c/l^ Designer Information Designer Name: A/^ /^c?/^os-^:/ _ Phone: 7/<T-37^- >-/ I ^^ Designer Address: 'P-o. 3 o/c S-z-z- :j>o ^ tjR. u -e-f/- v.<y J: zip: S~-^SY~7 J E-mail.' "^'° n l/ ^- ^ eA ''"^ ^^ <^->&^-0 i/~f~^-'' <— 0 1^/\ This space reserved for approval Stamp. License Number: -z^-o^O Remarks: Signature:Date:^/_3C-2J Original signature required on each submitted copy. ?>T&•* - »^"1 "" s +, ^^'p- ^?^v\^\@^^7d c ,( f e -^ £» € ^ Sl ' M ®> P ; U -3 ' " • s \ ^ 1- 1 A IS - » e -8 0 . . O j t- E i ^ ^ - S ^ ) ° 1 ?^ t & ^ ( f t ? t ? S o^ c s . 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N' " ^ s; f F t 35 ^ ^ ' • ~ ^ . ^t 'i S i oi S t l ^^1 § 1 i^ i ^ f < <» ? $ § i ^ sT V ^ I ?§ ^ . ^ »y O T ^ . i - (w i - ^ - f 5 ^ ® ^i - ^ % ^ tr i F S p F - S y " a l^ ^ l l T %i?^ i J & •»< .ll f r ^ ^ 5 U| J S J_ ' ^ ' " ^ '3 ? ' y 3y ^ / £S3 ? IEUTJ] ,_o C~~lC3C^i 0'} lcyy] I&S QSS •s-<p~Qco '< 2 4" CAST-A-SEAL TOP VIEW OPTIONAL FLAT COVERIS AVAILABLE FOR EXCHANGEFOR DOME COVER. WLP750-MR TANK SPECIFICATIONS DIMENSIONS:WALL: 2 1/2" BOTTOM: 3"COVER: 4"MANHOLE: 24" I.D. PRECAST CONCRETE RISERHEIGHT: DOME COVER 61" O.D.FLAT COVER 55 1/4" O.D. OUTSIDE DIAMETER: 84" O.D.BELOW INLET: 42" O.D. LIQUID LEVEL: 57" WEIGHT: 6,150 LBS. INLET AND OUTLET:4" CAST-A-SEAL BOOT OR EQUALGASKET, CAST-A-SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER:WISCONSIN, SEE DETAIL #10(OTHER STATES SEE CHART) LIQUID CAPACITY: 20.28 GAL/IN HOLDING TANK:ACTUAL CAPACITT: 790 GALLONS"OUTLET HOLE PLUGGED LOADING DESIGN: 8' 0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #S (NO FIBER)TANK: MIX DESIGN #W (STRUCTURAL FIBER) CUSTOMIZED TANKS:FOR CUSTOM TANKS CONTACT WIESER CONCRETE PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: CD8 inOL ^- z 00GSQ |i ins M1^2 I>- 0s 01 00w3 CMIsI 5 0FPLLUW LUCK SHEET NO. 1 .OF 1 POWTS OWNER'S MANUAL & MANAGEMEN- FILE INFORMATION SYSTEM SPECIFICATIONS E pE ^ LAN Page"MAY 1 3 'iM Owner -r/^n s/c^^ Permit # DESIGN PARAMETERS Number of Bedrooms Number of Public Facility Units Estimated (average) flow Design (peak) flow = (Estimated x 1.5) In Situ Soil Application Rate Standard Influent/Effluent Quality Fats, Oil & Grease (FOG) Biochemical Oxygen Demand (BODs) Total Suspended Solids (TSS) Pretreated Effluent Quality Biochemical Oxygen Demand (BODs) Total Suspended Solids (TSS) Fecal Coliform (geometric mean) Maximum Effluent Particle Size Other: 2- DNA ^NA T^G gal/day_ 3 c'£> gal/day . "7 gal/day/ft2 Monthly average* S30 mg/L <220 mg/L @ NA <150mg/L Monthly average ^30 mg/L s:30 mg/L IS1 NA <104cfu/100ml 1/6 in dia. IS NA [&]NA Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Tank Manufacturer U&'agfS^Co.fe'rfft^epf. IS Septic D Dose D Holding Tank Manufacturer D Septic D Dose D Holding Effluent Filter Manufacturer Pd Effluent Filter Model p t 5" Pump Manufacturer Pump Model Pretreatment Unit D Sand/Gravel Filter D Mechanical Aeration D Disinfection Manufacturer Dispersal Cell (s) gl In-Ground (gravity) a At-Grade D Drip-Line Other: Other: vol. '7^'o vol. cJ^JoC- -z€ D Peat Filter D Wetland a Other: DNA gal SNA gal DNA SNA BNA DNA D In-Ground (pressurized) D Mound D Other: g^NA @NA Service Event Inspect condition of tank(s) Pump out contents of tank(s) Inspect dispersal cell(s) Clean effluent filter Inspect pump, pump controls & alarm Flush laterals and pressure test Other: Other: Service Frequency At least once every: ^ § ^r% (Maximum 3 years) D NA g3 When combined sludge and scum equals one-third (%) of tank volume @ When the high water alarm is activated At least once every: ^ § 51e^) (Maximum 3 years) D NA At least once every:monthjs) Q ^Ayear(s) At least once every: ^ g m^f D NA At least once every: g ^%(s) E NA At least once every:^ mclnthx(s) la NA3 year(s) BNA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the affluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of efftuent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (1/6) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of $12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (12/02) '2. of 2. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: a A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. D A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate asuitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. «WARNING»SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOTENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF APERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS . Name Phone INSTALLER ^ I lan f3fc|^&s -71 5- 2-C|2^-<^S ^ 'i C Pf-^ ^6 k. Pi^mki -(ft SEPTAGE SERVICING OPERATOR (PUMPER) Name Phone -T^&nA&S P&,H€ -7^5- 3-7-2.- ff '.c>5l€.i C^rcl f^^er^e.f 30^ POWTS Name Phone MAINTAINER Al.lc.^'p^lk •7SS' 2-92-- :oS y, k^(7^/ f5-^ ^oS^.'?^*^It w LOCAL REGULATORY AUTHORITY r&j Name 3<ay-T.€(<l C^o^'i-y "Z.o^<^ -71 ^ 3-? ^-& (5^ /Phone -71 5' 2>"? ^ This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Private Sewage System Maintenance Agreement Owner(s) Name -r^ $'('<L-M'<^ Owner(s) Mailing Address •?^3 Sl~6>ro.)cTr. A^o^ ^^ci^k ^A/5T<9^| Site Address %2^s~ ^ I 'r M 00^ L; k& t?»- ^ c ^ '^ 1 ^-e ^ m r^/j?^| ^Tax ID #3^^ Iip As owner, I (we) do hereby certify the private sewage system will be installed in accordance with the certified soil tester's report and approved plans and specificationson file with Bayfield County Planning and Zoning Department. The system will beoperated in such a manner as to meet ths designed plans. I (we) agree to maintain saidprivate system at the below listed location In accordance with rules established in the WlAdm. Code, as from time to time amended. (COMPLETE Legal Is required) -1/4 of _.1/4 Section 1L .Township 1T-N.Range.<3 _w. Additional Legal Description; ^[^- Mcff^ i^ J^-e S<,4cjJ~-eS V Town of T t^^ ^ ?- • ^^- <" (Acreage) _ Gov'tLot. Lot _2_ Block_ Subdivision ^<?/-P Mco.i L-/ ^ ^s-^. je^ Lot..CSM#_Vol..-Page.CSMDoc#. DOCUMENT NUMBER2025R-607375 DANIEL. J. HEF-F-NER REGISTER OF DEEDS BAYFIELD COUNTY, Wl RECORDED 05/05/2025 AT 1 1:20 AM RECORDING FEE: $30.00 PAGES: 1 Ro'-'ord'ns A'SS! Return To; 1e> ^ 'f>Q / d f.O.' "B^!C S"' "^-o ^ /^. J e.^ In-ground gravity D Mound D In-ground dosed D In-ground pressure distribution Sewage System: D At-grade Sewage System D Other. Septte Tank (system types A through B): The septlc tank shall be pumped by a certified septage servicing operator within three (3) years of the date of Installation and at least once every three (3) years thereafter unless, upon Inspection by a licensed master plumber or other person authorized to make such Inspection, the tank is found to have less than one-thlrd (1/3) of the volume occupied by sludge and scum. Pump Chamber (system types B, C, D, and E): The pump chamber shall also be rlnsed and pumped out when the septlc tank is serviced as provided above. The switches and pump controls shall also be inspected and maintained to ensure operablllty of said components. Septlc Tank Effluent Filter (system types A through E): The septlc tank effluent filter shall be inspected and maintained as necessary and in accordancewith manufacturer's specifications. Filter maintenance reports shall be submitted to the County as required by SPS 383.55, Wis. Admin, Code. Private Sewage System Dispersal Cell (system types A through E): The private sewage system distribution cell shall be visually inspected by a certified septage servicing operator, POWTS Inspector, or licensed master plumber within three (3) years of the date of Installation and at [east once every three (3) years thereafter to determine whether wastewater or effluent from the system is ponding on the ground surface. Mounds. At-arade. and In-around Pressure System Laterals (system types C, D and E): The laterals shall be flushed out and swabbedif needed when the wastewater distribution cell component Is Inspected as provided above. Owner(s) agree that failure to comply with this agreement will result in action being taken to pay all charges and costs Incurred by Bayfleld County for inspection, pumping, hauling, or otherwise servicing and maintaining the private sewage system tank in such a manner as to prevent or abate anyhuman health hazard caused by the system. Bayfleld County shall notify the owner of any costs which shall be paid by the owner within thirty (30) daysfrom the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. The terms and conditions of the agreement shall be binding upon and Inure to the benefit of all current and future owners of such property. Owner(s) Name(s) - Please Print >TTyv\ ScernrM No:arlzei^)wner(s) - Slgnature(s) ^^^^S) Subscribed and sworn to before me on this date: A'f^t- Z^, ^02.6 Notary Public^^V\^/' ~^\^t[y^ My Commission Expires: I- ^-l- T-D"^^ Drafted bvF^n^fff / ^5 k; Date: *f^^<HEATHER BILLETTE SLETTEN NOTARY PUBLIC^^^^5Q^orms/sanlt^/septicmalntBnceagr8ement My Commi»»Kr.^x|}i»»t Jan. 31. 2026 Proofed by: Revised July 2020 Co A ^€^ATaC^l£M BAYFIELD COUNTYCHECKLIST FOR SANITARY APPLICATONS Submit the Following (Use Permanent Ink) (Title 15, Section 15-l-10(e)) IM Check List Bayfield Co, Zoning Dept Sf Original Sanitary Application (Submitted in Deed Holders Name - not prospective buyers) (383.21(1)1.) Ef Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) Ef Original Plot Plan (383.22(2)2. 3. & 4.a) @3 Cross Section, Over-Head Profile of the System and Schematic of Tank from Manufacturer D Pump Tank Diagram, Alarm and Pump Curve (when applicable) Qi Contingency Plan / Management Plan (383.22-3(2)(b)l.f.) ST Maintenance Agreement (Owner's Original Signature) (383.2l(2)(c)(5),(6) (Recorded at Reg. of Deeds) D Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) D Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)5) D ATU Servicing Agreement (Recorded at Reg. of Deeds) Fee (Make Check Payable to Bayfield County Zoning) (383,21(2)(c)7) Ef. CQme!ete Set of Plans (383.22(2)(2.) (Note: Sanitary Application and MaintenanceAgreements are to be attached to all copies) GJ Soil and Site Evaluation Report (383.22-3(2)(b)l.e.) D State Plan Review (when applicable) D Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) Ef I Application Information must include: D 23 digit Parcel ID# -- (do not use 12 digits anymore-obsolete) El Project Address or Road Name where driveway is/will come off of) E (Owners Phone Number) ^ 11 Type of Building a III Type of Permit Bf IV Type of POWTS System St V Dispersal / Treatment Area Information Tank Information Ef VII Responsibility Statement (Plumber's Information) D *Date Stamp* Plot Plan: (To Scale or To Dimension) Ef Signature and Plumber Information Ef Address Number and Road Ef Surface Elevation of Body of Water 12f North Arrow G3 Direction and Percent Land Slope Ef Contour Lines [gf Tank and Filter Information and Location Ef Structures and Driveways 0' Wetlands / Navigable Bodies of Water E Boring Locations G3' Absorption Area (Proposed and Existing) E( Property Lines 0 Bench Mark (Location, Elevation and Description) 0 Well Locations Ef Component Manual Version Ef Legal Descriptions ^ PIN§9|!"*'^!]|aN^^ Turn Over > Cross-Section and Over-Head Profile of the System; In] ^ ^ i | ^ jnlI -i^L1"1 ^ !pl Surface and System Elevation IJii ; ; J ^- Ly 0'Position of Observation and Vent Pipes r;n,,,i,^; pn 7, ,,»;r> i ^wd.jcjy^iu vu. ^UH?( ^ ^-'^p if Dimensions and Depths Make, Model & Number of Chamber Units in each Cell Property Information D How many systems will there be on this parcel of land? J- a Has this property been split? 3U o (Property Statement shows Property History) Fees: El Private Sewage System (Septic Tanks) $ 400.00 D Private Sewage System (Holding Tanks) $ 400.00 D Mounds or Systems requiring Pre-Treatment $ 500.00 D Sanitary Revisions $ 25.00 D Private Sewage System Reconnection $ 50.00 and Private Interceptor D Return Inspection $ 50.00 0 Maintenance Agreements ^ $ 30.00 (checks made out to Reg of Deeds) u/forms/checktists/checklistforsanitaryapps(l0/2009);(®7/2011);(®2/2012)(®5/2/2012-dc) Proofed by: