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39347_NC DOT_20041004
C CAMA / DREDGE & FILL GENERAL PERMIT Previous permit# ❑New ]Modification ]Complete Reissue .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 I SA NCAC Rules attached. Applicant Name__ Project Location: County Address____,_ _ Street Address/ State Road/ Lot #(s) City _ State___ ZIP Phone # ( ) ! 'U Fax # ( ) Authorized Agent ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS Affected AEC(s): r OEA ❑ HHF ❑ IH ❑ USA ❑ N/A C PWS: ❑FC: ORW: yes / no PNA yes / no Crit. Hab. yes / no Type of Project/ Activity Pier (dock) length Platform(s) Finger pier(s) Groin length number Bulkhead/ Riprap length avg distance offshore max distance offshore Basin, channel 7a Boat ramp Boathouse/ Boatlift Beach Bulldozing Other I Shoreline Length SAV: not sure yes nc Sandbags: not sure yes nc Moratorium: n/a yes nc Photos: yes nc Waiver Attached: yes no A building permit may be required by: Notes/ Special Conditions Agent or Applicant Printed Name Signature Please read compliance statement on back of permit Subdivision CityZIP i' Phone # ( ) _ _ River Basin `'1.{.. Adj. Wtr. Body gnat /man /unkn) Closest Maj. Wtr. Body= (Scale: `- ' ' ' ) See note on back regarding River Basin rules. Permit Officer's Signature Issuing Date Expiration Date ApplicationFee(s) Check# Local Plan ningJurisdiction 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: Xi 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 (910-395-3900) for more information on how to comply with thesebuffer rules. Division of Coastal Management Offices Central Office Mailing Address: 1638 Mail Service Center Raleigh, NC 27699-1638 Location: Parker -Lincoln Building 2728 Capital Blvd. Raleigh, NC 27604 919-733-2293 / 1-888-4RCOAST Fax:919-733-1495 Elizabeth City District 1367 U.S. 17 South Elizabeth City, NC 27909 252-264-3901 Fax:252-264-3723 (Serves: Camden, Chowan, Currituck, Dare, Gates, Pasquotank and Perquimans Counties) Morehead City District 151-B Hwy. 24 Hestron Plaza II Morehead City, NC 28557 202-808-2808 Fax: 252-247-3330 (Serves: Carteret, Craven, Onslow -above New River Inlet- and Pamlico Counties) Washington District 943 Washington Square Mall Washington, NC 27889 252-946-6481 Fax: 252-948-0478 (Serves: Beaufort, Bertie, Hertford, Hyde, Tyrrell and Washington Counties) Wilmington District 127 Cardinal Drive Ext. Wilmington, NC 28405-3845 910-395-3900 Fax:910-350-2004 (Serves: Brunswick, New Hanover, Onslow -below New River Inlet- and Pender Counties) www.nccoastaimanagement.net Revised 10/05/01 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 October 5, 2004 N.C. Department of Transportation Attn: Jaye Johnson P.O. Box 1587 Greenville, N.C. 27835 Dear Mr. Johnson: Attached is General Permit #39347-C to replace a culvert at the crossing of Riggs Creek, SR 1324, in the Community of Florence. In order to validate this permit, please sign all three (3) copies 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, S4� Bill Arrington Coastal Management Representative Enclosures BA/rcb 151-6 Hwy. 24, Hestron Plaza II, Morehead City, North Carolina 28557 Phone: 252-808-28081 FAX: 252-247-33301 Internet: www.nccoastalmanagemenf.net Form DCM-MP-5 BRIDGES AND CULVERTS 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. 1. BRIDGES a. Public X 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 j. Will the proposed bridge affect existing water flow? Revised 03/95 _ _Yes No If yes, explain k. Navigation clearance underneath proposed bridge Will the proposed bridge affect navigation by reducing or increasing the existing navigable opening? Yes _ No If yes, explain m. 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 Riggs Creek b. Number of culverts proposed 1 Q 66" x 51" x 40' Corrugated Metal Pipe c. Type of culvert (construction material, style) Aluminum d. Will proposed culvert replace an existing bridge? Yes X 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) e. Will proposed culvert replace an existing culvert? X Yes _ No If yes, Form DCM-MP-5 (1) Length of existing culvert 36' (2) Width of existing culvert 48" (3) Height of the top of the existing culvert above the MHW or NWL 20.4" (4) Will all, or a part of, the existing culvert be removed? (Explain)Yes, The existing culvert will be removed and replaced with the new culvert. f. Length of proposed culvert 40' g. Width of proposed culvert 1 @ 66"x 51" h. Height of the top of the proposed culvert above the MHW or NWL 23.4" Will the proposed culvert affect existing water flow? Yes X No If yes, explain Will the proposed culvert affect existing navigation potential? Yes X No If yes, explain 3. EXCAVATION AND FILL 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 43' (2) Width of area to be excavated 9.5' (3) Depth of area to be excavated (4) Amount of material to be excavated in cubic yards 408.5 sq. ft 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' (2) Width of area to be excavated 6' (3) Amount of material to be excavated in cubic yards 36 Sq. Ft Will the placement of the proposed bridge or culvert require any highground excavation? X Yes No If yes, (1) Length of area to be excavated 36' (2) Width of area to be excavated 21.35' (3) Amount of material to be excavated in cubic yards 768.6 Sq. Ft d. If the placement of the bridge or culvert involves any 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. 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 If yes, (1) Length of area to be filled 40' (2) Width of area to be filled 9.5' (3) Purpose of fill Backfill with gravel for bedding of the culvert 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: Coastal Wetlands SAVs Other Wetlands If yes, No (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 Form DCM-MP-5 4. GENERAL a. Will the proposed project involve any mitigation? Yes X No If yes, explain in detail b. Will the proposed project require the relocation of any existing utility lines? Yes X No If yes, explain in detail 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 RipRap Nvill be placed at the ends of the Dice NCDOT-Pamlico SR 1324 Florence Rd Applicant or Pr 'ect Name Signature 8/i Date Revised 03/95 PLAN VIEW Hazel Gallo Michael Collier Hawes 1711 Tryon Rd. 1314 Heritage Dr. Bern, NC 28560 Bern,New New Be, NC 28562 (Deed Bic #186, Pg. 7) (Deed Bk. #285, Pg. 441 c n � z I c n 2 ¢ c u I ¢ a c o c - C v C [ u C cc c •, idily Qateiin n u I n n 0 sO.-CAMA 6 8 I 8 6 (per JAJ, 7)6104 1 I Riggs Creek., 0 I I � 7a © I I T.'1 sting 48" x 36' — pi 1 18 sgft-LAMA AREA 1 1 Proposed 64 x 51' x i0' cm pipe arcq (derJAJ. 7Br04) CLASS B (GRANITE) RIPRAP OPEN WATER IMPA EA2 ------- .— — — CLASS B (GRANITE) RIPRAP 18 sgR-CAMAA (per JAJ, 7rB104) 1 Fbw - Riggs Credo O I ©0 1 0EkWATER IMPACT 0 sgfl -CAMA I I I I I I I (per JAJ, 7&04)—'------- Roy B. Carraway I I I I I Mary S. Mullins 7145 Florence Rd. 6908 Florence Rd. Mernt, NC 285% Merrit, NC 285% (Deed Bk. #165, Pg. 47) (Deed Bk. #319, Pg. 380) NORTH NOTE: DRAWING IS NOT TO SCALE OPEN WATER IMPACTS AREA 1= 9.5'x 7'= 66.5 scA AREA 2=9.5'xT=66.5 sqfL 133.0 Total PROJECT N0.2M.206911 Pi failure w/undermined RDWY DATE: 8/12/04 ROAD: SR 1324 ROAD NAME FLORENCE COUNTY: PAMLICO DRAWN BY: BG LfTTLETON,JR. PROJECT NO. 2M.206911 Pipe failure w/undermined RDWY DATE: 7/23/04 ROAD: SR 1324 ROAD NAME FLORENCE RD COUNTY: PAMLICO DRAWN BY: BG LITTLETON,JR. SR 1324 AREA TO BE EXCAVATED CROSS SECTION OF PIPE CROSSING ROUND TYPE PIPE UNDERCUT & BACKFILL EXISTING 48" X 36' CMP 2.0' 2o.a„ EXISTING 48" X 36' CMP a.a NWL 27.8 * ��, i `__ BEDDING (12" MIN) NOT TO SCALE PROPOSED 66" X 51 " X 40' CM PIPE ARCH 1SIR 1324 21.35' ZV PROPOSED Sr X 51" CMP ARCH 23.4" 51 7.75' NWL 27.6" I 12' MINIMUM BEDDING 18' WASHED STONE :::::::::::"::;:;:;:;: UNDERCUT& BACKFILL TOE OF SLOPE 2R 20 21.39 X 36' = 768.6 sq.ft. EXCAVATION BELOW NWL: 9.5'x36'= 342.0 9.5'XT = 66.5 sq.ft. 408.5 sa.ft. = TOTAL 23.4" - 24" = 47.4" OR 3.95' X 1.5 = 5.925' X 2 (SIDES) = 11.85' + 9.5' =21.35' (TOTAL WIDTH) NOTE: SLOPE REQUIRED FOR TYPE "C" SOIL = 1.5' : V (EXCAVATION REQ'D TO REMOVE EXISTING PIPE) (SEE SLOPE METHOD CALCULATIONS) (EXCAVATION REQ'D TO REMOVE EXISTING PIPE) (ADDITIONAL EXCAVATION REQ'D TO SET NEW PIPE) FINISHED EARTH SLOPE AS REQUIRED RIPRAP OUTLET PROTECTION (TYP) NWL W T -G15 i - � i 12a0 — i 44 _ — _ _ _-- MESIC L ` Vpy � �O - P O I l� C p s \. ( - ems. -� i 11OUYVILLE Co 04 Iwn fo/. 100 b7 CMy `.C29 ° ! 1002 1215 • \ VANDEMERE ror. 313 1 1216 \ 0 _ , • 1213 121s 1218 1206 Cann.1217 raW g0 H — _Swap ?.W" C.. 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City, State, ZtP+4 rn c � LI T, nIC .... ..... —.-- ..-.-.-. - Z, ss� Certified Mail Provides: (as�anay)zooza�nr'ooae�ojsd ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS® postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or j addressee's authorized agent. Advise the clerk or mark the mailpiece with the i endorsement "Restricted -Delivery". ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. 57R 13 Z 7 PAm I''CD ■ 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: �o s . mu►I ►.NS ffi c kUT/ NC Jr" r? 4P A. Signature 1 X n n It [4D ed by (Printed fd OI e ry �, Mery address differ t f m 1? Y s if YES, enter delivery atrrtgf. low: _ 3. Sepoide Type Certified Mail ❑ Express Mail 0 Registered 0 Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes t 2. Article Number (Transfer from service label) 7003 1010 0002 6599 516 5 PS Form 3811, August 2001 Domestic Return Receipt 2ACPRl-03-P-4081', UNITED STATES POSTAL SERVICE First -Class Mail Postage & Fees Paid LISPS Permit No. G-10 • Sender: Please print your name, address, and ZIP+4 in this box • 9. 7 i lie, �v'G L;cn 11ricu IVIAILTii KCI;Cir t {Domestic Mail Only; No Insurance Coverage Provides For delivery information visit our website at www.usps.Com,6, OFFICIAL USE -11 Postage I $ . 83 1 ru Certified Fee M M 0 Return Re -A Fee (Endorsement RegWred) nd.. (EFee ment Req. lred) Total Postage & Fees i c61 Sent To �+- Street A L No.; / .................... -- ---------- or PO ... I. ..... n CN ----• , t .fir City, State, -...•...._ Z(P+4 �- PS Form 3800, June 22 See Reverse for Instructiorm-- �, � s � c� Certified Mail Provides: (as a�ar�) zooa Bunr'ooeE wood Sd ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Maile or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS® postmark on your Certified Mail receipt is required. it For an additional fee, delivery may be restricted to the addressee or addresseeg authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restrlctede1iVery'• ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mall addressed to APOs and FPOs. �j (Z 13 2-4 ■ 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: A. ❑ Agent B. hekived by (PdWej Name) I C. pale of D. Is delivery address different from item 1? L3 Yes if YES, enter delivery address below: ❑ No 3. Service Type Seertified Mail ❑ Express Mail D Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number (Transfer from service label) 7 0 0 3 1010 0002 6599 5141 PS Form 3811, August 2001 Domestic Return Receipt 2ACPRI.03-P-4081 UNITED STATES POSTAL * Sender: Please print PM First-Classmalf— Postage & Fees-Pek� uSPS Permit No. G-10L.,—. e, address, and ZIP+4 in this box • ri C- -�)'-T- 0 153 7 QZ�V)jjff 96, -0 Ir r_q Lj') Er Er U F F I C I Ln Postage $O ru E-1 Certified F. ED Retum Recle Fee ntReq! (Endorsement red) RestrictedDeliveryFee (Endorsement Required) E3 r-4 Total Postage & Fees A L LEE' m C3 e t7o. r....................... .0 rPO ..... ............ cc=Z to Q I q 3 juu, june m Certified Mail Provides: tasa�aa)Z00ZeUnr.00a> WJo�sd ■ A mailing receipt ■ A unique identifier for your maitpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE_ COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse maitpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized aqent. Advise the clerk or mark the mailpiece with the endorsement "Restricted elivery". ■ if a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mall addressed to APOs and FPOs. ■ 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. r, 1. Article Addressed to: ��RRlTT ti 7145 F- e,JcE, 1 . Z8 55G A. Signal X 7 Agent D. Is deliverl address different fromitem 1? U Ye if YES, enter delivery address below: ❑ No 3. Service Type $'Certif". all ❑ Registered ❑ Insured Mail ❑ Express Mail ❑ Return Receipt for Merchandise ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number (Transfer from service lab( 7003 1010 0002 6599 5134 ',PS Form 3811, August 2001 Domestic Return Receipt 2ACPR1-03 P-aoai' UNITED STATES POSTAL SERVICE First -Class Mail Postage & Fees Paid USPS Permit No. G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Nc- `DC) -- o 15 2 -7 Go-eF-,,Jv llZ, IVC.- 2-7 83 6- f5:I Iii9:d�:aFt.:lii5ial1.�14..F111cx .1 { t :• ,x<. n 1E.1 Ln -D Postage $ r, O CertKed Fee are; M Re Return RFee° (Endorsement Required) 1 .��+ Here R /f) (EndoorrseemdeDt gWred) f• ; j ` . i C1 Total Postage & Feesior-treet, Apt. NIA PrP0BoxNo)LI9,r--,c) bL— �"A ,- LD A T I n Certified Mail Provides: (asianaa)ZooZeunr'ooBeu1jodSd ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail®. ■ Certified Mail is not available for any class of international mail. in NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery, To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS® postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized Sppent. Advise the clerk or mark the mailpiece with the endorsement "Restricted -Delivery" ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. I [Mil"ER. COMPLETESECTION -------------------------- ■ 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: r aa�(A3 A. Signature �� ❑ Agent XC ,L�"—"'h[] Addressee B. Received b Tinted Name) C. D to of elive D. Is de�ijr�ry address different from item -1 ❑ Yes If YES, enter delivery address below: ❑ No 3. Service Type ,13CCertified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (EXtV Fee) 2 Article Number Yes (Transfer from servlce laae/J 7003 1010 0002 6 5 9 9 5196 PS Form 3811, February 2004 Domestic Return Receipt P 102595-02-M•1540 UNITED STATES POSTAL SERVECE L Firat-Class Mail �J{{ Postage & Fees paid GUSPS :W ,i Permit No. G-10 ` and Z(P+4 in this box Sender: Please print yoar�-name, address; • G- \�eec--�\) \\\e) Ln rq Ln Er Irl OFFICIAL USE Ln FU Postage Certified Fee $ .23 M m m Return R-Iept Fee (Endorsement Required) M rq RestrictedDellvAruyiFee (Endor em, ntR rem oo� 0 Total Postage & Fees $ 4L )? m M Sent To PG ----- c, ... AA 17�- Nfi;R"Awf W. .. ........... or PO Box No. �eP-MAG-F *'j Certified Mail Provides. `Doss mod sd ■ A mailing receipt f asjwal zoo? sunr `D ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail®. ■ Certified Mail is not available for any class of international mail. is NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a LISPS® postmark on your Certified Mail receipt is required. lit For an additional fee, delivery may be restricted to the addressee or addressee's aulhoft6d a, nt. Advise the clerk or mark the mailpiece with the endorsement "Restricted elivery". ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. if a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. SR :a ;a Postage $ 03 ru Certified o Fee NV/� E` Retum Redept Fee (Endorsement Required) i S O Restricted Oellvery Fee (Endorsement Requlred) Total Postage R Fees $ m p ux c3 Sent To j j f O L ��. 'l n [` Streef, Apt No.: T ---- or PO Sox No. Ciry, Srata, ZlP+4 ....................... Certified Mail Provides: ■ A mailing receipt (asianay) zppZ eunf'poes urjod Sd } ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years i Important Reminders. ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressees authOflZed aggent. Advise the clerk or mark the mailpiece with the endorsement "Restricted )ivery". ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mall addressed to APOs and FPOs. s� 13 4�C�o