47215_NC DOT_20060830

❑CAMA / ❑ DREDGE & FILL r -
GENERAL PERMIT Previous mit#
❑New ❑Modification El Complete Reissue El Partial Reissue Date prev us 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 attach
Applicant Name t
Address 1
City
Phone #
Authorized Agent
❑ CW
❑ EW
Affected
AEC(s): ❑ OEA
❑ HHF
❑ PWS:
ORW: yes / no
PNA
Type of Project/ Activity
State ZIP'
Fax # ( )
❑ PTA [I -ES ❑ PTS
❑IH ❑UBA ❑N/A
❑ FC:
yes / no Crit. Flfati yes / no
Project Location: County /c
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin
Adj. Wtr. Body _.E : gat)/man /unkn)
Closest Maj. Wtr. Body
(Scale: N )
Pier (dock) length
Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
-- ----
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing
Other
Shoreline Length
SAM 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:
Notes/ Special Conditions
_i See note on back regarding River Basin rules.
C C ra � ��nn ' �'r��'" 'tom• —
AgentorApplicantPrintedName 6 Permit Officer's Signature f�3o'�
Signature Please read compliance statemen ty DCVgDate Expiration Date
ApplicationFee(s) Check# Local PlannipSjurisdiction 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 1) 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 how to comply with these buffer rules.
Division of Coastal Management Offices
Central Office
Elizabeth City District
Washington District
Mailing Address:
1367 U.S. 17 South
943 Washington Square Mall
1638 Mail Service Center
Elizabeth City, NC 27909
Washington, NC 27889
Raleigh, NC 27699-1638
252-264-3901
252-946-6481
Location:
Fax: [phone]
Fax: [phone]
Parker -Lincoln Building
(Serves: Camden, Chowan, Currituck,
(Serves: Beaufort, Bertie, Hertford, Hyde,
2728 Capital Blvd.
Dare, Gates, Pasquotank and Perquimans
Tyrrell and Washington Counties)
Counties)
Raleigh, NC 27604
919-733-2293
Morehead City District
Wilmington District
Fax: [phone]
400 Commerce Ave
127 Cardinal Drive Ext.
Morehead City, NC 28557
Wilmington, NC 28405-3845
202-808-2808/ 1-888-4RCOAST
910-796-7215
Fax: [phone]
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
(Serves: Brunswick, New Hanover,
New River Inlet- and Pamlico Counties)
Orslow -below New River Inlet- and
Pender Counties)
Revised 06/29/05

C-�CAMA / &-6REDGE & FILL
N? 47215
GENERAL PERMIT
2" K -ew ElModification ❑Complete Reissue ❑Partial Reissue
Previous permit #
Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
6 [ �3
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
�
Applicant Name �/ f
N �
ens attached.
Project Location: County tiv^�(t O
l��
�
Address 4 U Y X (s Y 7
Street Address/ State Road/ Lot #(s)
City v/ e- State LJCZIP
_� a��/i''`C. 1'0fi/_l ✓, c?' �l! C g-r—
Phone # (a r� b'? a -? Y ga Fax # ( )
r— _...-..-- - - -- - ---- -
Subdivision
Authorized Agent s `� J a
City_ - ���-' � -__ .X Af ZIP.-. ---7 _
Affected �-� [` PTA f�TE� El
Phone # ( ) __- River Basin Va -� k
F-
OEA HHP IH UBA ❑ N/A
AEC(s):
-',Fc:
1
Adj. Wtr. Body_ _� �/�1^ _ nat /man.[unkn)
Pws:
ORW: / 0o PNA / Crit. Hab. / no
Closest Maj. Wtr. Body k A " -�
yes yes yes
a
Type of Project/ Activity �v'��,��fi y X Y� ����� t <z e7(�u A^ ` X yo, c.-/'"t
Pier (dock) length
Platform(s) _
Finger pier(s) ._
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp _
Boathouse/ Boatlift
Beach Bulldozing `,
Other <fj ✓u� T ?�' 7 p r
r
Shoreline Length N
(Scale: Rr d ,l —
)
it
SAM not sure yes y " ^ -'
Sandbags: not sure yes 0
Moratorium: n/a yes © _ — _ qj L-1
Photos: yes
Waiver Attached: yes no p
A building permit may be required by:
l!ll / �� I rc �' _-�See note on back regarding River Basin rules.
Notes/ Special Conditions W / re f-11wed . f r,-,tr I a -v-r! N -,ce4 f" `^i" f,j
rr"'S�G,..^Ir
l •�` I' tY-LaW 1LY %w`� I � .B.f G✓a'1'�f1 N .� .. I(• W � ��� �J��yc.
Agent or Applicant Printed Name
Z&4�� -, Y�-�
Permit Officer's Signature
r 7 0 -a G //- Y
Signature **Please read compliance statement on back of permit"
�000rlJ.Gr/V,.��6�l1
Issuing Date Expiration Date
A -

DOT PERMIT FEE BILLING REQUEST
Date: August 31, 2006
To: Dale Schmidt
From: Ronda Bennett
Transfer Amount: $100.00
DOT Project Description: Culvert replacement SR 1360 Oriental
DCM Permit Type and Number: General Permit 47215
Fee Division if Applicable: (record amounts to be split with DWQ, if applicable)
DCM: 100.00
DWQ:
WBS Element Number: 2.206911

a
ALT7i`1'waA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Charles S. Jones, Director William G. Ross Jr., Secretary
August 31, 2006
NC DOT
P.O. Box 1587
Greenville, N.C. 27834
Dear Jay Johnson:
Attached is General Permit #47215C- to replace an existing 30' X 40' culvert at SR 1360,
Oriental, North Carolina, with a 42' X 40' culvert .
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 permit 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
SL/rcb
Enclosures
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] \ FAX: [phone] \ Internet: www.nccoastaimanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled \ 10% Post Consumer Paper

Form DCM-MP-5
BRIDGES AND
CULVERTS
$100.00 Processing Fee
NCDOT WBS NO.2.206911
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.
BRIDGES N/A
a. Public Private
b. Type of bridge (construction material)
c. Water body to be crossed by bridge
d. Water depth at the proposed crossing at MLW or
NWL
e. Will proposed bridge replace an existing bridge?
_Yes No
If yes,
(1) Length of existing bridge
(2) Width of existing bridge
(3) Navigation clearance underneath existing
bridge
(4) Will all, or a part of, the existing bridge be
removed? (Explain).
f. Will proposed bridge replace an existing culvert(s)?
Yes No
If yes,
(1) Length of existing culvert
(2) Width of existing culvert
(3) Height of the top of the existing culvert above
the MHW or NWL
(4) Will all, or a part of, the existing culvert be
removed? (Explain)
g. Length of proposed bridge
h. Width of proposed bridge
i. Height of proposed bridge above wetlands
Revised 03/95
AUG 1 a 2006
Morehead City DCM
j. Will the proposed bridge affect existing water flow?
_ _Yes No
If yes, explain
k. Navigation clearance underneath proposed bridge
1. Will the proposed bridge affect navigation by
reducing or increasing the existing navigable
opening? Yes _ No
If yes, explain
in. Will the proposed bridge cross wetlands containing
no navigable waters? Yes No
If yes, explain
n. Have you contacted the U.S. Coast Guard concerning
their approval?
Yes No
If yes, please provide record of their action.
2. CULVERTS
a. Water body in which culvert is to be placed Camp
Creek
b. Number of culverts proposed I
c. Type of culvert (construction material, style)
CORRUGATED METAL PIPE
d. Will proposed culvert replace an existing bridge?
Yes _ _X_No
If yes,
(1) Length of existing bridge N/A
(2) Width of existing bridge N/A
(3) Navigation clearance underneath existing
bridge N/A
(4) Will all, or a part of, the existing bridge be
removed? (Explain)

Form DCM-MP-5
e. Will proposed culvert replace an existing culvert?
_ X Yes _ No
If yes,
(1) Length of existing culvert 40'
(2) Width of existing culvert 30"
(3) Height of the top of the existing culvert above
the MHW or NWL 2.0'
(4) Will all, or a part of, the existing culvert be
removed? (Explain) YES
f. Length of proposed culvert40'
g. Width of proposed culvert 42"
h. Height of the top of the proposed culvert above the
MHW or NWL 2.0'
Will the proposed culvert affect existing water flow?
Yes X No
If yes, explain
Will the proposed culvert affect
potential? Yes X No
If yes, explain
existing navigation
3. EXCAVATION AND FILL
a. Will the placement of the proposed bridge or culvert
require any excavation below the MHW or NWL?
X _ _Yes No
If yes,
(1) Length of area to be excavated 50'
(2) Width of area to be excavated 7.5'
(3) Depth of area to be excavated 2'
(4) Amount of material to be excavated in cubic
yards 375 SOUARE FEET
b. Will the placement of the proposed bridge or culvert
require any excavation within:
X Coastal Wetlands SAVs _Other
Wetlands
If yes,
(1) Length of area to be excavated 6.93'
(2) Width of area to be excavated 6.93'
(3) Approximate area to be excavated
48Fe
c. Will the placement of the proposed bridge or culvert
require any high ground excavation? X Yes
No
If yes,
(1) Length of area to be excavated 44'
Ica�
(2) Width of be excavated
fflD
(3) Amount mate*j Go jbeje�8Wted in cubic
yards 286 SQUARE FEET
d. If the placemeJKbAg.&_d_rany
excavation, please complete the following:
(1) Location of the spoil disposal area
Temporary spoil area is existing road bed
(2) Dimensions of spoil disposal area
20' x 20'
(3) Do you claim title to the disposal area?
X Yes No
If no, attach a letter granting permission from
the owner.
(4) Will the disposal area be available for future
maintenance? X Yes No
(5) Does the disposal area include any coastal
wetlands (marsh), SAVs, or other wetlands?
Yes X No
If yes, give dimensions if different from (2)
above.
(6) Does the disposal area include any area below
the MHW or NWL? Yes X No
If yes, give dimension if different from No. 2
above.
e. Will the placement of the proposed bridge or culvert
result in any fill (other than excavated material
described in Item d. above) to be placed below MHW
or NWL? X Yes — No Open Water Impacts
If yes,
(1) Length of area to be filled 5'
(2) Width of area to be filled 5.5'
(3) Purpose of fill For Pipe Bedding and
Cover
f. Will the placement of the proposed bridge or culvert
result
in any fill (other than excavated material
described
in Item d. above) to be placed within: N/A
Coastal Wetlands SAVs Other
Wetlands
If yes,
(1)
Length of area to be filled _
(2)
Width of area to be filled
(3)
Purpose of fill
g. Will the placement of the proposed bridge or culvert
result in any fill (other than excavated material
described in Item d. above) to be placed on
highground? _Yes X No
If yes,
(1) Length of area to be filled
(2) Width of area to be filled
(3) Purpose of fill
Revised 03/95

14
Form DCM-MP-5
4. GENERAL
a. Will the proposed project involve any mitigation?
_ Yes No X
If yes, explain in detail
0
Will the proposed project
any existing utility lines? _
If yes, explain in detail —
require the relocation of
_ Yes X No
c. Will the proposed project require the construction of
any temporary detour structures?
Yes X No
If yes, explain in detail
d. Will the proposed project require any work channels?
Yes X No
If yes, complete Form DCM-MP-2
e. How will excavated or fill material be kept on site
and erosion controlled? Silt fence
f. What type of construction equipment will be used
(for example, dragline, backhoe or hydraulic dredge)?
Typical Bridge construction equipment
g. Will wetlands be crossed in transporting equipment to
project site? Yes X No
If yes, explain steps that will be taken to lessen
environmental impacts.
h. Will the placement of the proposed bridge or culvert
require any shoreline stabilization?
_ _Yes X No
If yes, explain in detail
NCDOT-Pamlico Countv Pioe Replacement on Sr
1360
Applicant or Pro'ect Name
Signature
Date 07/31/06
PICS9
AUG 1 4 2806
ZS
Morehead Citj,
DcM
Revised 03/95

S 'CIEudzll
1 p°j� i * eeO�9A ,T 00 U
PIPE REPLACEMENT Morehead Cit
SR 1360, NORTH STREET ORIENTAL
PAMLICO COUNTY
ORIENTAL USGS QUAD MAP
ine
4- — n�n Vista
J/' a N 35 01 — 53 _
W 76^-41'-45"
co
N
PROJECT".,. -, t
cj
14
e^ ( e
-
d
tlilt
WBS ELEMENT NO. 2.206911 Implatfotm
Xa-
ti 0 435 870 1,740 2,610 3,4Peet
M

0
PIPE REPLACEMENT AUG 14
SR 1360, NORTH STREET ORalgFaAlC
PAMLICO COUNTY
ORIENTAL USGS QUAD MAP
m Ine View D
ea Vista
�a
o°
�renr oo�� PROJECT N
W E
laOkwell point
Coop Rd v ° s
Jam �
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Q° F ti° ° c
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co Hodges t N
so WBS ELEMENT
o� NUMBER 2.206911
I VICINITY MAP
0 437.5 875 1,750 2,625 3,5
I
CM

a a
n OOD FARMS, LLC
2 23 HIGHWAY NC 55
AREA Q NTAL NC 28571
Ze 395.PG. 463 CLASS RIPRA
16 S
OF WET'QND IMPACTS I
P
CAMP CREEK I
mx0m I
co r
a' 9� o TURBIDITY CURTAIN
5.5' xx I
EXISTING R/W I I AREA 5 1
CAMP CREEK PARTNERS.LLC
403 FACTORY STREET
ORIENTAL, NC 28571
DBK. 448, PG. 385
FOR PERMITTING ONLY,
NOT FOR CONSTRUCTION
EXISTING R/W
- -
- - - - - - - - - - - - - - - - - - -
-
- - - - - - - -
AREA :I--'
AREA 2 AREA
2 16 SO.FT.
L . 4y
y �1
OF COASTAL WETLAND IMPACTS
y y`y y y i
y y ,! y'
TF (TOE / WATERS EDGE)
--y - ----�--y- `�--�- y--`�
-y------- - -- '
----- _--------- ------
- SP (SHOULDER POINT)
EXISTING 40'x30" CMP
7•
- - - - - - - - - - - - - - - - - - - - - - - - - - L - - J -
- - - - - - - - - - - - - - - - - - -
- EP (EDGE OF PAVEMENT)
NORTH STREET
SR 1360 '
rn
350'± TO NC 55
IL.
MIDYETTE STREET —
PROPOSED 40'X42" CMP
------------------- - - - - -- - - -- -
----------------- - - -
-EP (EDGE OF PAVEMENT)
0.61 MILES TO JCT. SR 1319
\I y y y y y y y 4 - y
- --- - - - - -- -may
- - y y y -y -y - - - - - -
y y V y 3-
- SP (SHOULDER POINT)
y y J�
�L,�--- -
�yy yy
- TF (TOE / WATERS EDGE)
AREA 4. ;--
y y AEA 3
-------------------
XISTING R/W
+ -��
x
LAS�'B RIf�i2Ai�--------------------'----
JOHAN C.DE NIJS I AREA 6 I
AREA 3
EXISTING R/W
AND
GSTREY DE NIJS 1
5.5
8 SO, FT ,
NORTH
605 NORTH STREET X
ORIENTAL, NC 28571 x
OF COASTAL WETLAND IMPACTS
DBK.246. PG.342 TURBIDITY CURAIN
I ERNEST C. DUNN, Jr.
AREA 4
T�Oq
AND MARY CLYDE DUNN
8 SO. FT. 1 m
1 5007 TOPSAIL
ao
OF COASTAL WETLAND IMPACTS I o
ORIENTAL, NC 28571
I DBK. 335, PG. 534
CAMP CREEK NOTE: THIS PROJECT
IS IN THE NEUSE RIVER BASIN
NEUSE BUFFER RULES
APPLY
COASTAL
WETLANDS IMPACT
AREA •I =
16 SO FT
NORTH CAROLINA
AREA 2 =
16 SO FT SR 1360
DEPARTMENT OF TRANSPORTATION
OPEN WATER IMPACTS
AREA. 3 =
8 SO FT PAMLICO COUNTY
AREA 5 = 5' x 5.5' = 27.5 Sq Ft
ARLA 4 =
8 SO FT PROPOSED PIPE REPLACEMENT
AREA 6 = 5 x 5.5' = 27.5 Sq Ft
TOTAL AREA = 48 SO FT CAMA GP APPLICATION
TOTAL AREA = 55 Sq Ft

2.206911 CROSS SEC Tlo
JULY 3/.2"wa
OF
1360 CULVERT CRO
NORTH STREET SR, 1360 q lI G 1 4
P4ML ICO PAMLICO COUNTY zoos
PIPE REPLACEMSead City DCM
EXISTING 409a30" CMP
PROPOSED 40'a42" CMP
EXISTING 4O'x30°CMP
SR 1360
-WL
AREA TO W EXCAVATED
A10 MCIDrILL®
yy 2.5'
- 17-
ui •—/ NOT TO SCALE
SAW
I! %- 7 1
PROPOSED 40'x42N CMP
ARE
I EXCAVATION ABOVE NWL:
I
65'w x 44'L x 2'd = 286 SQUARE FEET
EXCAVATION BELOW NWL
7S'w x 50'L x 2'd = J75 SQUARE FEET
i
w
co
N
D:
FINISHED EARTH SLOPE AS REQUIRED
PROPOSED RIP RAP o END
OF PIPE

F
■ Complete items 1, 2, and 3. Also complete
iterh 4 if Restricted Delivery is desired.
■ 'PHj1t your name and address on the reverse
so that we can return the card to you.
■ Attach this.,dard to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
A/
&o 5 All v r2T�/ ST
©eJf1V7;AL, NU
'8591
A.
' ❑ Agent
/ ❑ Addre
by ( Printed Name) // I C.
D. Is delivery address different from Rem 1? ❑ Yes
If YES, enter delivery address below: 0 No
3. ice Type
SeCertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
0 Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(Transfer from service label) 7004 1350 0001 4558 2175
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

UNITED STATES POSTAL SERVICE
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, addre
NC f o r AUG 1 4 Z006
o • _Sa Mdr'r-bnQad City PCIA
Cr���,✓v�l��,
2-783
m. , Sumo
??i??liii?ii??ii3.i???1ii2.i?•i:Eii? :i•..fi{i??il??

■ 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:
Z 7-72-
9 ►2J6011-2-L , N G
2. Article Number
(Transfer from service label)
PS Form 3811, February 2004'
A. Signature
X ❑Agent
GlAddressee
B. Received by Printed ame) C.,ONf Kelly ry
D. Is delivery address different from item 1? f u Xes
If YES, enter delivery address below: ❑ No
3. Service Type
Certified Mail ❑ Express Mail
Registered ❑ Return Receipt for Merchandise i
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
7004 1350 0001 4558 2212
102595.02 M 1540

UNITED STATES POSTAL SERVICE
First -Class Mail
Postage & Fees Paid
LISPS
Permit No. G-10
• Sender: Please print your name, ad IAUGAA I I IUG I
1 4 2006
-p rehlead City DCM
27S135

■ 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.
1 ■ Attach this card to the back of the mailpiece,
or on the front if space permits.
?, 1. Article Addressed to:
b JNA) I �i .
5007 7oP6A1z-
2857/
A. Signature
`_
X i tul'
B. Received by QPrinted Name)
❑ Agent
❑ Addressee i
D. Is delivery address different from item 11 ❑ Yes
If YES, enter delivery address below: ❑ No
3. SeS ice Type
O1 Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7004 1350 Cool 4 5 5 8
(Transfer from service Labe 2205
PS Form 3811, February 2004 Domestic Return Receipt
1- - - - - 102595-02-M-1540

UNITED STATES POSTAL SERVICE First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
EI
• Sender: Please print your name, Fs,"6ndTZ11P",+"
ii
/V C Z�:, oT AUG 1 4 2006
amity mm
1�6, NC 2-7835
----------------

■ 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 tq the back :otthe mailpiece,
or on the front if space permits.
1. Article Addressed to:
.4n 3 FA�r--m lLj 57-:
Z.85?1
/�. Signat e 99/
L f�.� 0, Agent
X
Addressee
�. Recei by ( Printed Name) C. Date of Delivery
D. delivery address different fromrt em 1? ❑ 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
(rransfer from service label) 7 4 1350 L11 4558 2182
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1w 1'1

UNITED STATES POSTAL SERVICE First -Class Mail
Postage & Fees Paid
usr=o
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
t: *1�
r
1 4
15972
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