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WEL2023-00026 - WEL Application, Design, Letter - 5/3/2023
n. MASON COUNTY 415 N 6TH STREET,SHELTON, ,WA 98584 SHELTON:360-427-9670 EXT 400 BELFAIR:360-275-4467, EXT 400 P Public Health & Human Services ELMA: 360-482 5269,EXT 400 FAX:360-427-7787 LACY DIAN 900 W Carman Rd S SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00026 900 W Carman Rd S 420213290023 The 2-party water system, Lacy Water System, has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater management around the water source. If you have any questions, please contact me at or email at Danderson@masoncountywa.gov Sinc ly, David Anderson Mason County Environmental Health k /r, 4,--.P,.l,, IPArgt..4\` 4Date Received: s pT, MASON COUNTY.•i COMMUNITY SERVICES Arno*Received Recei Bolding.Planning,Environmental Health,Community Health �� 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 S Y E L 4Z6 26 0 34 Shelton: 360-427-9670 x400 Belfair:360-2754467 x400 Elma:360-482-5269 x400 ��V .......--- TWO-PARTY PRIVATE WATER SYSTEM APPLICATION mom APPLICANT p'• c -, i,otc v PHONE (L� , . f` 7 7 V /, MAILING ADDRESS-STREET,CITY,STATE,ZIP `J _ 1 }'� `' / 900W Carm20 IZO0,-d D S SherV ^�) WA- D SITE ADDRESS-STREET,CITY,STATE.ZIP t, t, PRIMARY PARCEL NUMBER(WELL SITE) 42-0LI — 3 2 - ' 002 SECONDARY PARCEL NUMBER(IF APPLICABLE) 11Z02- I — 3 Z - c100Z2. WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE 0 New *Existing ,L.Well 0 Spring •, 149 q p,c f S i,15 OiC✓e) PROPOSED WATER SYSTEM NAME(REQUIRED) �4(y tv OW 52-5 PROJECT DESCRIPTION -1.9 arfiil (A i I — -eY(S 11 to O y, -heir✓tom DIRECTIONS TO SITE/CONDITIONS ^ re$ e 5 i ( (� c - GSM ',vAi,19 Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,e ...) 4, S Pie AC iY�.(il S�.v r— p I0L fi MAY ,g 20223 RFCFi frED Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) 71 Septic Records (additional locating requirements may apply if there is a lack of septic records on file) This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021 Page 1 of 2 bia l -162 0 LA-4 lOd C ff Use Only Review Step 1: Well Site Inspection: d ?/D fence ctf roo(U1 f Gttvi fy wa,rl d L jl ku,d,phi,- Con j �C/f/�r11/C l� c4 c�ih'�`nt�I ,,,-' G YES NO NA - f/Svrfq� wh 56 ' b( (1(7,02 • C�(:1NC;G ] ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? l (drainfields, tanks, buildings; indicate distance on plot plan) 0 ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is roa private; ounty or State. What is distance to ROW? 3 2 10 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ] ] ❑ ❑ Is the well cap satisfactory? ❑ I ❑ Screened and vented? 1, ❑ The well casing extends I.•J above level ground/concrete slab? (circle one) ❑ ❑ ] Is there evidence of a surface seal? (e7 6'e{€ 5(0 o LG1; lg.LO70 NZO It ❑ ❑ Does the seal appear adequate? CUN . —I Z3.10 I&y 7G ❑ tp ❑ Is a variance necessary for well site approval? 7Citi ; ly/l,i Comments I(,�j`oVe1 fr Veil stye, ctri, Pass ❑ Fail Inspector Date 6/Z(2(7 Z3 Review Step 2: Two-Party Review: YES NO NA 71 ❑ ❑ Water Well Report with adequate pump test on file?If NO, date of Capacity Test Driller 1 1 ,/C f GPM I; ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test (((t?/7�/. 3 v ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z (?66 � [v ❑ ❑ System appears adequate to serve 2 single-family residencesid based on information provided? Comments /L f Zo 23 ' QeCel l plc �vV 0 S O` ultavt Cat v11 p 'IUV t,f 9-il Approved ❑ Denied Reviewer Date l6' /5/ Z0/3 Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,express or implied of the future success or failure of this system. Well site approval does not constitute water system approval. Water System approval is a two-part process. All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19h, 2018 per ESSB 6091. �W MINIIMot, S —„� Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 2196694 MASON CO WA 05/03/2023 10.35 AM NOTCE III III III III III IIIII II I III 0 IIIII IIIII1 lI I�IN IIIII II Return To c LaC`J coo Co ma.r Rd S Shei-to h 1N 9(650 Li Grantor(s): (1) d L-Ps C S , (2) Grantee(s): (1) PUBLIC Legal Description (1) LO+ SP .a 5 7 I (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) `t 2 0 2- 1 - 3 2- 9 0 0 2 3 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned grantor(s), certify that the water source located on the above-described real estate under Legal Description (1) and Assessors Tax Parcel (1) situated in Mason County, State of Washington, has been designated to serve a source of water to the following parcels situated in Mason County, State of Washington; herein described: Tax Parcel: (Connection 1) 2 D )-- 1 3 2- q 0 0 2 3 Tax Parcel: (Connection 2) 4 Z D z ( -3 2- 0 0 2- 2- The system owner is responsible for keeping this system in compliance. The name of the water system is: This system is designed to provide for two service connections. Planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Additionally, a water right, obtained from the Department of Ecology, is required if the water system exceeds exemption standards. This system (has/ has not) been granted one or more waivers from specific provisions of the regulations. Dated on this Aft‹ 1 J , 20 Signature of Grantor(s): (1) , (2) Page 1 of 2 State of Washington County of Mason I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this f( day of fI-y00 I , , r)1ait) personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (they) signed it. GIVEN and r h n day and y ar last above written. JULIE M NICHOLS Notary Public State of Washington License Number 151930 Notary Public in and for the State of Washington, My Commission Expires residing at O 1 4 yt,t i 6t ` February 15, 2027 My commission expires: 2- IS,2-7 Page 2 of 2 ow. Thurston County Environmental Health\ �.e� 2000 Lakeridge Dr.SW •Olympia,WA 98502 401-ii 360 867-2631 THURS C N COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected ---Time Sample County Colected Monk Day Year oPM Type of Water System(check only one box) Private Household ❑Group A 0 Group B Other_ — -7 Group A and Group B Systems-Provide from Water Facilities Inventory(WFI 10# 7:74e4A-) t-JAY-#.‘ System Name ' ,V./ - ,p-- 7 co Z� Contact Person: SF LQ/yL.{„....J N3 Day Phone:( .-,C) Cell Phone:( ) E-mail:alt� C�.,. Eve.Phone:( ) Send results to.(Print'ull nave,address a zip code or 'address Z- Ctm. 63 1 fiAlC.r P_(:)_ _ ScF .Cc _ SAMPLE INFORMATION Sample collected by(name) I cms_s✓ . l 1,3 Specific location or address where sample collected: Special instructions or comments: 4 Etj Type of Sample(must check only one box of#1 through#4 listed below) jRoutine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No/1 0 Distribution System Chlonne Residual:Total_Free_ Chlorinated:Yes _No 3.Raw Water Source Sample Chlorine Residual Total Free_ ❑E.coil-GWR(A/P) ❑Fecal-Surface.GM,apnnps lm,nw.ronl Unsatisfactory routine lab number: Filtered.Yes-_.__-.No-_.. ❑Assessment Monitoring(A1P) Unsatisfactory routine collect date ❑Other ----1-----f--- ----- S I 4.0 Sample Collected for Information Only Investigative __--_ Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and tisfactory 0 E.coii present 0 E.co8 I absent Co dorm detected 0 Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC 0 Bacterial Density Results:Total Coldorrn /100m1. E.co& ____._1100m1. Fecal Colifoml __/100m1 Enterocooci /100 ml. 4 Method Code:gSM 92238 ❑SM 9222D Date and Time Received:74-er. ❑SM 92158 ❑Enterolefl* +- 11"7 P Al Date and Tine Anatyzed: - VI- •2 OM REat 'f b-7.3atg- Saliva,Number(DOH smear plus live digits) Lab Use Only. 0 8 0 l (, DOH F m 331.319(rarsed a1116 A C.X.G a 682U 361 Ito • r. WATER NELL REPORT Start Card No. W101324 Unique Well I.P. a AEC982 STATE OF WASHINGTON Water Riyht Permit No 11) OWNER: Name LACY, RICHARD Address W 900 CARMEN ROAD S SHELTON, WAT 98584-'i• _____ 21. CD 12) LOCATION OF WRLL: County MASON - NW 1/4 SW 1/4 Sec 21 T 20N N., R 4W WM IX (2a) STREET ADDRESS OF WELL (or nearest address) N 900 CARMEN ROAD B. SHELTON d 01 PROPOSED USE: DOMESTIC (10) WELL LOG (4) TYPE OF WORK: ' N Owner's Number of well Formation: Describe by color, ::haracter. size of material - IA (If more than one) and structure, and show thickness of aquifers and the kind tNEW NELL Method: ROTARY and nature of the material in each stratum penet.ret.ed, rnII: idi at least one entry for each chants in formation. _ (51 DIMENSIONS: Diameter of well 6 inches 0 Drilled 86 ft. Depth of completed well 80 ft. MATERIAL I FROM ro - - _ SANDY BROWN CLAY 0 3 0 (61 CONSTRUCTION DETAILS: GRAVEL COURSE BROWN SAND 3 5 ij Casing installed: 6 " Dia. from .1.6 ft. to 86.4 ft. PACKED COURSE SAND GRAVEL 5 18 03 WELDED CASING " Dia. from ft. to ft. NET COURSE SAND GRAVEL 18 20 • E " Dia. from ft. to ft. GRAY CLAY 20 j 35 Be BROWS COURSE SAND GRAVID. s WATER 35 39 0 Perforations: NO BLACK GRAVEL COURSE SAND GRY CLAY BINDER 39 58 C Type of perforator used BROWN COURSE SAND GRAVEL 58 I 63 SIZE of perforations in. by in. COURSE SAND WATER SONS GRAVEL 63 86 0 perforations from ft. to ft. SANDY BROND CLAY 86 6 perforations from ft. to ft. L. perforations from ft. to ft. 0"a Screens: YES Manufacturer's Name HOUSTON R Type SLOTTED Model No. ,D 03 niam. 5 slot size 000 from 79.6 ft. to B0.6 ft. a ,X3 f` 4-5 Diem. 5 slot sine .025 from 90.6 ft. to 85.6 ft. ` '. graveliii of7 ' O C,ravel packed: NO Size CD Gravel placed from ft. to ft. ....' 4e, Surface seal: YES To what depth? 20 ft. Material used in seal BENTONITE 1: Did any strata contain unusable water? NO 0 Type of water? Depth of strata ft. _. L Method of sealing strata off (7) PUMP: Manufacturer's Name Type H.P. O (8) WATER LEVELS: Land-surface elevation Z above mean sea level ... ft. H Static level 33 ft. below top of well Date 06/08/98 Artesian Pressure lbs. per square inch Date 414 Artesian water controlled by P Com leted 06/08/98 Work started 06/06/98 CM (9) WELL TESTS: Drawdowr. is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION: 0 static level. I constructed and/or accept responsibility for con • Was a pump rest. made? NO If yes, by whom? etruction of this well, and its compliance with all 0 Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used and the information reported above are true to my beet W knowledge and belief. O Recovery data Time Water l,ovrl Time Water Level Time Water Level NAME ARCADIA DRILLING INC. 4., ;Person, firm, or corporation) (Type or print) EADDRESS SE 170 WALKER PARE RD Date test / / ,,....— License No. 1149 � Bailer testt 1 gal/min- ft. drawdown after his. [SIGNED) + CI. Air test 15 gal/min. w/ stem set at 80 ft. for 1 hrs. CO Artesian flow g.p.m. Date Contractor's Q Temperature of watr.'r Was a chemical analysis made? NO Registration No. ARCADD:098K1 Date 96/69/9H --_ CO _. - 1— • MASON COUNTY HErAL1�H DEPARTMENT 428 WEST BIRCH STREET - - SHELTON, WASHINGTON 98584 "4aOg1 -3,2_ Too a 3 PHONE (206) 426-5561 RECORDEC� OF FINAL INSPECTION OF YOUR SEWAGE DISPOSAL SYSTEM OWNE���/� �//C �-~yyi ADDRESS/ t 5 .�`7, /l'}Z`i,, 9 .3 J THIS RECORD IS NOT A GUARAI�OF PERFORMANCE. LEGAL /, )J A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER DESCRIPTION "� �� Q.-X-C/ WITH PROPER MAINTENANCE AND CAREFUL USE OF aO WATER IT CAN GIVE MANY YEARS OF TROUBLE FREE SER- c--,2/ VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIL �f BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH COMMENTS �2/j- G 4ra. „F� AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE / FIELD X LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR ,NO. /J'/!✓2 ((�� SIZE FAULTY FIXTURES. DEPTH TO /_ /'` MONTH / �na��\ THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY WATER TABLE (p OF YEAR C`�'��7"` J TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE IN LlER) r_(49. C.[/D�/x/✓�e.MG '/` ��� FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND SIZE i THE AMOUNT THAT A GARBAGE DISPOSAL IS USED. CLEAN- SEPTIC TANK (S) /ae,O OQ,•ad, ] ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- FEET ING OR DESTROYING THE DRAINFIELD DUE TO SOLIDS DRAINFIELD / � / LENGTH / CARRYING OVER INTO THE DRAINFIELD. CALL THE TRENCH AREA SQ. MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF &i7� / LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE TILE // CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS DEPTH ❑ CORRUGATED RIGID ❑ CEMENT RECORD WHEN HE COMES. ROCK � ,4 LpH TOTAL W HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE CU. YDS. (O PIPE DEPTH DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD: SQ. FT. SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING NORTH ARE LATER CONTEMPLATED. SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO THE SEPTIC TANK AS THEY WOULD INTERFERE WITH CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE /]/ ,a e S /`- DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED. i_ v ! ' (/ vim- [j THE YARD GRADE IN THE DISPOSAL AREA SHOULD BE SUCH THAT SURFACE WATER IS NOT POCKETED ON THE DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE +� 9 TRENCHES SHOULD BE FILLED IN WITH SOIL. DO NOT EX- AO ��� CESSIVELY WATER THE LAWN IN THE DRAINFIELD AREA. WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT h -.- -------3' EQUAL TO ONE HALF INCH OF RAIN PER DAY. ff FOOTING DRAINAGE, DOWNSPOUTS AND WATER SOFTENER RECHARGE WATER SHOULD NOT BE CON- O r NECTED TO THE SEPTIC SYSTEM OR DISCHARGED INTO THE DRAINFIELD AREA. THE TYPES OF BACTERIA NEEDED IN A SEPTIC TANK ARE �� ALWAYS FOUND IN SEWAGE. THERE IS NO NEED TO ADD YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE- JUVENATORS OR CHEMICALS TO CLEAN A SEPTIC TANK HAVE NOT BEEN PROVEN TO BE BENEFICIAL AND MAY BE HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY CHANGING THE CHARACTERISTICS OF THE SOIL. THE NORMAL USE OF BOWL CLEANERS OR CLEANING COM- POUNDSWILL NOT KILL THE BACTERIAL ACTION OR SLOW � DOWN THE OPERATION OF THE SEPTIC TANK. ���A•-� ` pr6S=3-) THIS IS AN IMPORTANT DOCUMENT DATE BY �y PI WIT E D,O TH�`R. e Printed IE= T �. \wdLwfiiy Dy^"""^' �CO CERTIFIED BY Om Printed from Mason County OMS . .._-l. VS _ II11 • -- Ii 4RA/TV• G.• A/•1SON COUNTY HAS NO RESPONSIBILITY TO BUILD./ATPRoI AUWTAIN OP OTHRRISE SERVICE THE PRIVATE ROAD• do ANY, CONTAINED iNTHIN OR PROVIDING SERVICES 10 THHE PROPERTY DESCRIBED IN THIS SORT PLAT V. q W N • N 03.06'OB" E 0 342.23' 684.46' T c 425.07' TOTAL [� 67.57' �` 1` ,258.39 o o • � it • , .1 �\ a ci co a mp • I �A ' N m 41-/..... ...... $ ii ® + fit., + r;z �r ' , z 1 I L- 41 'J 1 - -r_-----------r - ! 4 u� 1tN ' -----� - y $ oos oer w i t, - - ___ _�--- coder :emm _ Q ' . o QO �`` 8 44 ''.1 , -X 2.- VI i C: z\-14. Cn ifA Q 1, R % _ � IO • u 1,C/ i. \:.....77..... ,.' p ti, 1 t N .''-W c. �4 L4 NI co • ��0::. ....---- IISS i gl 4 ..,. . t xt r LL . PRNATE EASEENI I ® `j• 98.•r . AIL 9 aez.zl' • N 0743'05 E r 1., CURVE RADIUS TANGENT LENGTH DELTA ' .•-.. 1 85.00' 21.48' 42-03' I 21320'02' 2 164.31' 30.00' 59.35' i 2041'4( ;j 3 215.34' 75.00' 144.34' 3524'21" MI C'P /\, C:›14 › Wei _ 111 NumACI 1 § qi r r" natio= , 6 .. 0 i 7,.. ,,,,iiti . i CIE11131313 k g i, DI m „ PtOne9 i ' C7.... io .6.. 2 ., ..41)p l'ea -4 i al; '-...-dO Q3 Zcn ‘• A, t �. . ,... o � 4 d O Z . a , I- ir.s. Ja! I Is A� a , m vc, 4y, ., „i,c ip { L ii U14 ; , L_.,1 M/ I - •' //yz/S ij - - ' 11 ' •N COUNTY-EAL!H DEPARTMENT FOR DEPARTMENT USE ONLY I ENVIRONMENTAL HEALTH SECTION RECE+PT DATE BASIS FOR F AMOUNT NUMBER 428 WEST BIRCH STREET • SHELTON, WA. 98584 _ o PHONE (206) 426-5561 7-JDg R�- ! /` •�0,O �e'�' APPLICANT SIGNATURE 6. 2 / ry�-o� _ ADDRE SS i'� ~� NOT (�p p� SITE: APP D ❑ APT •• R7Y OWNER • ^^-so BY: K J .,4- q'y1 a 1 ,j i',; DESIGNED SYSTEM REQUIRED r'/7 IQS � �'s6 2� CONTRACTOR W & -A. NOT CONTRACTOR — SEWAGE: AP VED ❑ OVED LEGAL SESCRIPTION j..R. BY: Trt>S. _—O L �_1[ � �, F Aki Lu-i- ' SOIL TYPE__ ? 11 /� BUILDIING J 0 to ! ( C. BEDROOMS 3 SIZE rC) X . DEPTH TO WATER TABLE PERC. RATE SINGLE RESIDENCE © PUBLIC WATER O NAME_ - SEPTIC TANK(S) 1 aoo GAL. PUMP REQ. WATER SYSTEM SYSTEM I COMMERCIAL ONLY LIQUID WASTE G.P.D DISTRIBUTION TILE TOTAL o-� FEET I . -- - - I DIRECTIONS TO SITE: FILTRATION AREA 305---- SQ. FEET QUANTITY OF ti k)Q) Lir `1 Ail I 1 r S 0 4 _ Ca zDin APPROVED STONE CU. YD. SAND CU. YD. fo c c/ t _ i L.c �1_S (ia{ mac » FILL REQUIRED CU. YDS. W FINAL INSPECTION REQUIRED BEFORE BACKFILLING B a ca � o nvc� • V�CJjj DEPTH OF Q� . . r S r C o - ,/ /i•,/C-kl, BACKFILL • . r � f� ! / !Y /- � 2"STRAW OR PAPER (J • .i.:•.; • '�i:i,• •• k. 1 2 J, I STONE .5..:•""ti ram• ':{40.,i,4 — 's i ;!f�O . ::_ltw _OVER TILE �:i�''4 ti-. ‘ .ray ♦' 4 ' PIPE SIZE ;;�4V•1*••••OQ:t1;:e A4' hl� 1. `,• ,FS •'� ttGi i7;os;1W' 6// STONE I ;3/ > I UNDER TILE SITE PLAN AND SPECIAL STIPULATIONS < L�.� (INDICATE DIRECTION OF DRAINAGE) �Cf/SS SECTION OF TRENC �/� d V14.1..a-4 Ill )()) iYt) t° — . $l`I' 0 Ate^' bitle)\° e9Q ( N V f I 1 COMMENTS: / P fined From Mac %n ON imy M3 L�'Z• THIS SITE PERMIT EXPIRES / / O Printer! from Mori County DMS - -