51290_NC DOT_20090507

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❑CAMA r ❑ DREDGE & FILL i t` 5290
GENERAL PERMIT Previous permit#
❑New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
_ ❑ Rules attached.
Applicant Name �' i Project Location: County
Address ��'`� / `s Street Address/ State Road/ Lot #(s)
City F.<:>, > StateJ4 < ZIP.-7
Phone # O '�30 = I Fax # (, )
Authorized Agent
Affected ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC:
ORW: yes / no PNA yes / no Crit.Hab. yes / no
Subdivision
City - ZIP
Phone # O River Basin
Adj. Wtr. Body (nat /man /unkn)
Closest Maj. Wtr. Body
Type of Project/ Activity
Pier (dock) length
1
Platform(s)
Finger pier(s)
. i (Scale:
Groin length
number
Bulkhead/ Riprap.length I
avg distance offshore
max distance offshore Ir
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift `
Beach Bulldozing
Other `
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Shoreline Length
SAV: not sure yes no
Sandbags: not sure yes no —
Moratorium: n/a yes no
Photos: ;yes' no
Waiver Attached: yes no`
A building permit may be required by: ��``' f" regarding {f •- � ' `0''See note on back re rdin River Basin rules.
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read_ compliance statement on back of permit
Application Fee(s) Check #
Permit Officer's Signature
Issuing Date Expiration Date
Local Planning Jurisdiction Rover File Name

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that [)prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s) .
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar- Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on howto complywith these buffer rules.
Division of Coastal Management Offices
Raleigh Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax:[phone]
Morehead City Headquarters
400 Commerce Ave
Morehead City, NC 28557
252-808-2808/ 1-888-4RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax:[phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax:[phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 08/09/06

9 AIVIA; I� REDGE & FILL N� 5129D
GgNERAL PERMIT Previous permit # Imo/%A
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued rl i
As authorized by the State of North Carolina, Department of Environment and Natural Resources jJ
and the Coastal Resources Commission in an area of environmental concern pursuant to l SA NCAC tJ 17 /1 ' f
��fiules attached.
Applicant Name C J +O IT" Project Location: County u' '
Address �%X /�� Street Address/ State Road/ Lot #(s) 1
City �i—-e�.�yfrll' State N C ziP��� �
�
Phone #,��}-�.'-3V
o 1 Fax #_(^
Authorized Agent ^y �d �'Ax's A
Affected ❑ Cw yf-g C-fA DES ❑ PTS
[IOEA ❑ HHF ❑ IH ElUBA ElN/A
AEC(s):
❑ PWS: ❑FC:
ORW: yes no, PNA yes / 661, Crit.Hab. yes / no
Subdivision
y
I�
City Lly�hj t 31 �' ZIP �L 7
Phone # () River Basin T;�
Adj. Wtr. Body V `T '1"a (nat /man o-
10',�' !ram;, ✓ zr
Closest Mal. Wtr. Body
Type of Project/Activityyyryf'�fNL�
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(Scale:
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Pier (dock) length
Platform(s)
Finger pier(s)
Groin length--F]
number `
Bulkhead/ ipra length
avg distance offshore4
max distance offshore
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing-'
Other
Shoreline Length
SAV: not sure yes nb
Sandbags: not sure yes no
Moratorium: n1a yes o
Photos: no
Waiver Attached: yes
A building permit may be required
Notes/ Special Conditions
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Agent or Applicant Printed Name
Sign** Please read compliance statement on back of permit
o0.00 €'V fit- DLC. 00-7o�L6
Application Fee(s) Check #
Permitofficer's rgnature r
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Issuing Date Expiration Date
Local Planning Jurisdiction Rover File Name

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Affl7,?"LWAA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
May 8, 2009
NCDOT
PO BOX 1587
Greenville, NC 27835
Dear Mr. Johnson:
Attached is General Permit #51290C to construct 54' of riprap for protection of shoreline
adjacent to road in Washington, NC
In order to validate this permit, please sign the permit as indicated. Retain the white copy for
your files and return the signed yellow and pink copies to us in the enclosed, self-addressed
envelope. If the signed pen -nit copies are not returned to this office before the initiation of
development, you will be working without authorization and will be subject to a Notice of
Violation and subsequent civil penalties.
We appreciate your early attention to this matter.
Sincerely,
Stephen Lane
Coastal Management Representative
Isb
Enclosures
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] \ FAX: [phone] \ Internet: www.nccoastalmanagement.net
An Equal Opportunity \ Affirmative Action Employer - 50% Recycled \ 10% Post Consumer Paper

IN Mr-1
APPLICATION for
Major Development Permit 4 2009
(last revised 12fZW06) Morel Seri-f city DCM
North Carolina DIVISION OF COASTAL MANAGEMENT
1. Primary Applicant Landowner Information
Business Name
North Carolina Department Of Transportation
Project Name (if applicable)
SR 1320, Shady Banks Road Beaufort County
Applicant 1: First Name
Jay
MI
B.
Last Name
Johnson
Applicant 2: First Name
MI
Last Name
If additional applicants, please attach an additional page(s) with names listed.
Mailing Address
PO Box
1587
City
Greenville
State
NC
ZIP
278351587
Country
us
Phone No.
252 - 830 - 3490 ext. 248
No.
F252- 830 - 3341
Street Address (if different from above)
City
State
ZIP
Email
[e-mail]
2. AgentContractor Information
Business Name
Agent/ Contractor 1: First Name
MI
Last Name
Agent/ Contractor 2: First Name
MI
Last Name
Mailing Address
PO Box
City
State
ZIP
Phone No. 1
-
- ext.
Phone No. 2
- - ext.
FAX No.
Contractor #
Street Address (if different from above)
City
State
ZIP
Email
<Form continues on back>

Form DCM MP-1 (Page 2 of 5)
APPLICATION for
Major Development Permit
3. Project Location
County (can be multiple)
Street Address
State Rd. #
Beaufort
SR 1320
Subdivision Name
City
State
Zip ��I!
Phone No.
Lot No.(s) (if many, attach additional page with list)
- - ext.
x
a. In which NC river basin is the project located?
b. Name of body of water nearest to proposed project
Tar -Pamlico
Un-Named Tributary
c. Is the water body identified in (b) above, natural or manmade?
d. Name the closest major water body to the proposed project site.
®Natural ❑Manmade ❑Unknown
Pamlico River
e. Is proposed work within city limits or planning jurisdiction?
f. If applicable, list the planning jurisdiction or city limit the proposed
❑Yes ®No
work falls within.
4.
Site Description
a.
Total length of shoreline on the tract (ft.)
b. Size of entire tract (sq.ft.)
75'
N/A
c.
Size of individual lot(s)
d. Approximate elevation of tract above NHW (normal high water) or
NWL (normal water level)
(if many lot sizes, please attach additional page with a list)
2.5' ❑NHW or ®NWL
e.
Vegetation on tract
Maintained Roadside Grasses
f.
Man-made features and uses now on tract
Road
g.
Identify and describe the existing land uses adjacent to the proposed project site.
Residential Property and Marina
h.
How does local government zone the tract?
i. Is the proposed project consistent with the applicable zoning?
N/A
(Attach zoning compliance certificate, if applicable)
❑Yes []No ®NA
j.
Is the proposed activity part of an urban waterfront redevelopment proposal? OYes ®No
k.
Hasa professional archaeological assessment been done for the tract? If yes, attach a copy. ❑Yes No ONA
If yes, by whom?
1.
Is the proposed project located in a National Registered Historic District or does it involve a Yes UNo EINA
National Register listed or eligible property?
<Form continues on next page>
m. (i) Are there wetlands on the site? ®Yes ❑No
(ii) Are there coastal wetlands on the site? ®Yes ❑No
(iii) If yes to either (i) or (ii) above, has a delineation been conducted? ®Yes []No
(Attach documentation, if available)

.Form DCM MP-1 (Page 3 of 5)
APPLICATION for
Major Development Permit
n. Describe existing wastewater treatment facilities.
N/A
o. Describe existing drinking water supply source.
N/A
p. Describe existing storm water management or treatment systems.
N/A
5. Activities and Impacts
a. Will the project be for commercial, public, or private use? ❑Commercial ®PublictGovemment
❑Private/Community
b. Give a brief description of purpose, use, and daily operations of the project when complete.
The Existing Bulkhead at this site has sustained significant deterioration, threatening the existing shoulder, thus making the
shoulder unsafe for the traveling public. Granite Rip -Rap will be placed on Filter Fabric for Slope Stabilization.
c. Describe the proposed construction methodology, types of construction equipment to be used during construction, the number of each type
of equipment and where it is to be stored.
Rip Rap will be placed on the shoulder and slope. Typical Roadway Construction Equipment Will Be Used, Including,But Not
Limited To Tracked Excavators,Dump Trucks, Flat -Bed Trucks, Back-Hoes,And Boom Trucks.
d. List all development activities you propose.
Shoulder and Slope Stabilization
e. Are the proposed activities maintenance of an existing project, new work, or both? New Work
f. What is the approximate total disturbed land area resulting from the proposed project? 1125 ®Sq.Ft or ❑Acres
g. Will the proposed project encroach on any public easement, public accessway or other area []Yes [:]No ENA
that the public has established use of?
h. Describe location and type of existing and proposed discharges to waters of the state.
N/A
i. Will wastewater or stormwater be discharged into a wetland? []Yes ®No ❑NA
If yes, will this discharged water be of the same salinity as the receiving water? ❑Yes ❑No ❑NA
j. Is there any mitigation proposed? Yes ONo NA
If yes, attach a mitigation proposal.
<Folrm continues on back>
6. AdditionalInformation
In addition to this completed application form, (MP-1) the following items below, if applicable, must be submitted in order for the application
package to be complete. Items (a) — (t) are always applicable to any major development application. Please consult the application
instruction booklet on how to properly prepare the required items below.
a. A project narrative.
b. An accurate, dated work plat (including plan view and cross -sectional drawings) drawn to scale. Please give the present status of the
proposed project. Is any portion already complete? If previously authorized work, clearly indicate on maps, plats, drawings to distinguish
between work completed and proposed.
c. A site or location map that is sufficiently detailed to guide agency personnel unfamiliar with the area to the site.

Form DCM MP-1 (Page 4 of 5)
APPLICATION for
Major Development Permit
d. A copy of the deed (with state application only) or other instrument under which the applicant claims title to the affected properties.
e. The appropriate application fee. Check or money order made payable to DENR.
f. A list of the names and complete addresses of the adjacent waterfront (riparian) landowners and signed return receipts as proof that such
owners have received a copy of the application and plats by certified mail. Such landowners must be advised that they have 30 days in
which to submit comments on the proposed project to the Division of Coastal Management.
Name Vickie C. Dotson
Phone No.
Address 236 East Main Street Washington, NC 27889
Name Linda K. Roberson
Phone No.
Address 484 Shady Banks Road Washington, NC 27889
Name
Phone No.
Address
g. A list of previous state or federal permits issued for work on the project tract. Include permit numbers, permittee, and issuing dates.
None
h. Signed consultant or agent authorization form, if applicable.
i. Wetland delineation, if necessary.
j. A signed AEC hazard notice for projects in oceanfront and inlet areas. (Must be signed by property owner)
k. A statement of compliance with the N.C. Environmental Policy Act (N.C.G.S. 113A 1-10), if necessary. If the project involves expenditure
of public funds or use of public lands, attach a statement documenting compliance with the North Carolina Environmental Policy Act.
1 7. Certification and Permission to Enter on Land
I understand that any permit issued in response to this application will allow only the development described in the application.
The project will be subject to the conditions and restrictions contained in the permit.
1 certify that I am authorized to grant, and do in fact grant permission to representatives of state and federal review agencies to
enter on the aforementioned lands in connection with evaluating information related to this permit application and follow-up
monitoring of the project.
I further certify that the information provided in this application is truthful to the best of my knowledge.
Date _April 9, 2009 Print Name _Jay B. Johnson
Signature _ Q� C�Z�
Please indicate application attachments pertaining to your pro sed project.
®DCM MP-2 Excavation and Fill Information ❑DCM MP-5 Bridges and Culverts
❑DCM MP-3 Upland Development
❑DCM MP-4 Structures Information

Form DCM MP-2 ,
EXCAVATION and FILL .`�/�4 2009
(Except for bridges and culverts) t'40r !head Vile/ DCM
f.r M
Attach this form to Joint Application for CAMA Major Permit, Form DCM MP-1. Be sure to complete all other sections of the Joint
Application that relate to this proposed project. Please include all supplemental information.
Describe below the purpose of proposed excavation and/or fill activities. All values should be given in feet.
Access
Other
Channel
Canal
Boat Basin
Boat Ramp
Rock Groin
Rock
(excluding
(NLW or
Breakwater
shoreline
NWL)
stabilization
Length
Width
Avg. Existing
NA
NA
Depth
Final Project
NA
NA
Depth
1. EXCAVATION ®This section not applicable
a. Amount of material to be excavated from below NHW or NWL in b. Type of material to be excavated.
cubic yards.
C. (i) Does the area to be excavated include coastal wetlands/marsh
(CW), submerged aquatic vegetation (SAV), shell bottom (SB),
or other wetlands (WL)? If any boxes are checked, provide the
number of square feet affected.
❑CW ❑SAV ❑SB
OWL ❑None
(ii) Describe the purpose of the excavation in these areas:
d. High -ground excavation in cubic yards.
12. DISPOSAL OF EXCAVATED MATERIAL ®This section not applicable
a. Location of disposal area.
C. (i) Do you claim title to disposal area?
[]Yes [:]No ❑NA
(ii) If no, attach a letter granting permission from the owner.
b. Dimensions of disposal area.
d. (i) Will a disposal area be available for future maintenance?
❑Yes []No ❑NA
(ii) If yes, where?
e. (i) Does the disposal area include any coastal wetlands/marsh f.
(CW), submerged aquatic vegetation (SAV), shell bottom (SB),
or other wetlands (WL)? If any boxes are checked, provide the
number of square feet affected.
❑CW ❑SAV ❑SB
❑WL ❑None
(ii) Describe the purpose of disposal in these areas:
(i) Does the disposal include any area in the water?
[]Yes []No ❑NA
(ii) If yes, how much water area is affected?
3. SHORELINE STABILIZATION ❑This section not applicable
(If development is a wood groin, use MP-4 — Structures)

Form DCM MP-2 (Excavation and Fill, Page 2 of 2)
a. Type of shoreline stabilization: b. Length: 75'
[]Bulkhead ®Riprap ❑Breakwater/Sill ❑Other: Width: 15'
c. Average distance waterward of NHW or NWL: 2' d. Maximum distance waterward of NHW or NWL:
.. _.P AO
e. Type of stabilization material:
Granite
g. Number of square feet of fill to be placed below water level
Bulkhead backfill Riprap 300 So. Ft.
Breakwater/Sill Other
i. Source of fill material.
NCDOT Borrow Pit
f. (i) Has there been shoreline erosion during preceding 12
months?
❑Yes ®No ❑NA
(ii) If yes, state amount of erosion and source of erosion amount
information.
h. Type of fill material.
Sand
4. OTHER FILL ACTIVITIES ®This section not applicable
(Excluding Shoreline Stabilization)
a. (i) Will fill material be brought to the site? []Yes []No EINA b. (i) Will fill material be placed in coastal wetlands/marsh (CW),
If yes,
(ii) Amount of material to be placed in the water
(iii) Dimensions of fill area
(iv) Purpose of fill
submerged aquatic vegetation (SAV), shell bottom (SB), or
other wetlands (WL)? If any boxes are checked, provide the
number of square feet affected.
❑CW ❑SAV ❑SB
OWL []None
(ii) Describe the purpose of the fill in these areas:
15. GENERAL
a. How will excavated or fill material be kept on site and erosion b. What type of construction equipment will be used (e.g., dragline,
controlled? backhoe, or hydraulic dredge)?
Filter Fabric and Rip Rap Typical Road Construction Equipment
c. (i) Will navigational aids be required as a result of the project? d. (i) Will wetlands be crossed in transporting equipment to project
❑Yes ®No ❑NA site? ❑Yes ®No ❑NA
(ii) If yes, explain what type and how they will be implemented. (ii) If yes, explain steps that will be taken to avoid or minimize
environmental impacts.
April 9, 2009 Ap
Date
SR 1320, Shady Banks Road Bulkhead Replacement
WBS Element Number 2C.007026
Project Name
Jay B. Johnson
plicant Name
plicant Signature
?O�—

SUMMARY OF AFFECTED PROPERTY OWNERS
TRACT
NUMBER
PROPERTY
OWNER
ADDRESS
5470
VICKIE C. DOTSON
236 EAST MAIN STREET
WASHINGTON, NC 27889
6436
LINDA K. ROBERSON
484 SHADY BANKS ROAD
WASHINGTON, NC 27889

E'-�• 4 1
14Y 4 2009
Morehe,ad City DCM
Rip Rap Placement For Bulkhead Replacement,
Shoulder, and Slope Stabilization, SR 1320, Shady
Banks Road,Beaufort County
Erosion Control Schedule
• Install erosion/sediment control measures according to plans.
• Grading of slopes; 1.5: 1= stabilize with Class B riprap
• Seed all disturbed areas as soon as final grading is completed.
• Clean out and/or rework all temporary sediment control measures after
significant rainfall event (or as otherwise needed). These measures should be
maintained until a permanent vegetative cover is established and project is
complete
• When Rip Rap is being placed,do not exceed 5 foot waterward from Normal
Water Level of Un-Named Tributary

SILT QASXW TYPE 1'
LEGEND SHEET
WETLANDS
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ELEVATION VIEW
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EDGE OF EXIST. ROAD
EXISTING FILL
UTILITIES LEGEND,
TYPICAL EACH SHEET
POWER POLE
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TELEPHONE PEDESTAL
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WATER VALVE
FIRE HYDRANT
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WATER METER
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PROPERTY LINE
GRASS -LINED CHANNEL
TRAPEZOIDAL DITCH SECTION
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TOP WIDTH (T) = 8 + 20Z
AREA TO BE �— 6
FILLED OR UNDISTURBED AREA
DISTURBED
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FABRIC BURIED BELOW
EXISTING GRA
SILT FENCE
DETAIL
NTS
I PROPOSED SILT FENCE
I y _+ ±
VAR.O'-G' WETLAND
EDGE OF EXIST. ROAD

® LEGEND SHEET
SPECIAL SEDIMENT CONTROL FENCE
3 FT. _
VAI
DIMS
CONTROL STONE
/4
SEDIMENT CONTRO
I FT. MIN.
WATER FLOW
1 \2_i cEL POST - 2 FT. DEEP
W00D POST - 3 FT. DEEP
GENERAL NOTES.
USE NO.3 OR NO.57 STONE FOR SEDIMENT
CONTROL AND PAY FOR AT THE CONTRACT UNIT
PRICE PER TON SEDIMENT CONTROL STONE
USE HARDWARE CLOTH 24 GAUGE WIRE MESH
WITH %4 INCH MESH OPENINGS
INSTALL 5 FT. SELF FASTENER ANGLE STEEL
POST 2 FT.DEEP MINIMUM
INSTALL 6 FT. LONG, 3 IN. DIA. WOOD POSTS
3_ FT. DEEP MINIMUM
SPACE POSTS A MAXIMUM OF 3 FT.
TURBIDITY CURTAIN
SILT BAG

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_� . _ _ _. �._ _. _�:.�.._._. ..m... ......_....._..w.�..� Feet
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5470
do VICKIE C. DOTSON
�90�
E
fo 236 EAST MAIN STREET
F 6436
WASH/NGTON, NC 27889
LINDA K. ROBERSON
DBK. 599, PG. 260
484 SHADY BANKS ROAD
PROPOSED BULKHEAD NOT TO EXCEED 5'WATERWARD,
FROM NORMAL WATER LEVEL OF TRIBUTARY
{
E WASH/NGrON,NC 27889
DBK. 940, PG. 258
WOODS
EXISTING TIMBER
BULKHEAD
TO BE REMOVED
EXISTING TIMBER BULKHEAD EXISTING R/W
DO NOT EXCEED EXISTING R/W
TO BE RETAINED
5-
TIE INTO EXISTING BULKHEAD HERE
PROPOSED RIP AP
o
N-) USE FILTER FABRIC
i
EXISTING EP
BENEATH RIP RAP
SR 1320
g
,
EXISTING PIPE
,
EXISTING PIPE
9'
i
i
SHADY BANKS ROAD
N 450 43' 43" E
EXISTING TIMBER BULKHEAD �EXISTING EP
ExIsrING R/W
BLOUNT'S BAY
CAMA GP APPLICATION
USGS QUAD MAP
m
SR /320, SHADY BANKS ROAD
SHEET NUMBER I3
OF THE
w
BULKHEAD REPLACEMENT
SOIL SURVEY OF
WBS ELEMENT NOo 2Co007026
BEAUFORT COUNTY
z
SCALEo l"=20'
FIRM PANEL 5694J
APRI L 9, 2009

SR t
FINISHED EARTH SLOPE AS REQUIRED \
FILTER FARR
CROSS SECTION OF
CULVERT CROSSING 4 2oa9
SR 1320, SHADY BANKS ROAD
BULKHEAD REPLACEMENT
PROPOSED RIP RAP
UN -NAMED TRIBUTARY
5.0'
PROPOSED RIP RAP @ END
O --P- - NWL
THE RIP RAP WILL NOT EXCEED 5' WATERWARD
FROM NORMAL WATER LEVEL OF THE TRIBUTARY

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Vickie C. Dotson
236 East Main St.
Washington, NC 27889
CLAY 4 -/oo9
Morehead City
A. Si re
X Xr
❑ Agent
❑ Addressee
B. Receiv d by (P fed Na
C. Da f Delivery
D. Is delivery address different from item 14 CI Yes
If YES, enter delivery address below: ❑ No
3. Service Type
$Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7008 1140 0002 0395 9 513
(Transfer from service fabeO
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
COMPLETE•N COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1, 2, and 3. Also complete nature
item 4 if Restricted Delivery is desired. ❑ Agent
■ Print your name and address on the reverse 0-Addressee
so that we can return the card to you. B. Re eived by (Printed Name) C. Date of Pebmu
■ Attach this card to the back of the mailpiece, ��
or on the front if space permits. '
D. Is delivery address different from Rem 1? O Yes
1. Article Addressed to: If YES, enter delivery address below: ❑ No
Linda Roberson 1
484 Shady Banks Rd.
Washington, NC 27889 3, se ertifiype
b� � Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service Labe 7008 1140 0002 0395 9520
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540