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:d Agent CovA.✓9,4 o A.JsoC„yfv City /3vL i vi/P ZIP 2 r5,2
❑CW (f R'PTA ❑ES ❑PTS Phone# ( ) River Basin L 4^r 6
❑OEA ❑HHF ❑IH ❑UBA ❑N/A
❑ ❑FC•
no Adj.Wtr. Body I#c/cG✓OG/j1 S /'c✓/ /?,v /n
'es PNA m/ no Crit. Hab. yes / no Closest Maj.Wtr.Body /9
/w4"/
Project/Activity en ✓A it_ P e2
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(Scale:
k)length 2 e 'x 6 ' ,
s)
r(s) -- _ -
fiber
/Riprap length
distance offshore distance offshore
1 L/ C(KlAc'ods froz f ✓R P/�
trine' f
is yards
P
e/Boatlift r
/c'
Ildozing
'
Length / 7o ;., ,`
not sure yes no' —
t '
not sure yes no
im: n/a yes no
�j _ N /
yes
f- f/t�x, 2/a9
no' �� / ��U}�. ��p
:tached: yes no p e -_ TO lli,E`2.4/_..G...e d'
g permit may be required by:,R,7 L.,,,,5 L./,e /1 C L,,,, . See note on back regarding River Basin rul
;pedal Conditions Cur Sia u e-lid,,,, /7u- f ea/v,(),,, ,,,/i/J 71/ /2G0 As we 1/
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Jtrrt an . L . r• ,9}7 . 2 -
•cant P ated Name Permit Officer's Signature
it ir••••••• 0 V/21/4 6 0
3/4041
`** lease re4compliance statement on back of permit** Issuing Date /J / xpiration Date
Fee(s) Check# Local Planning Jurisdiction -, Rover File Name

t.
•
SOUTHERN COMMUNITY BANK AND TRI
CAVANAUGH & ASSOCIATES, P.A. WINSTON-SALEM,NORTH CAROLINA 27
66-1209-531
305 WEST 4TH STREET,SUITE 1A
WINSTON SALEM,NC 27101 CHECK DP
[phone]
PAY One Hundred and 00/100 Dollars
NCDENR AN
TO 1612 Mail Service Center
Raleigh NC 27699
VOID AFTI
•
p Ytid/V
0000L70L61l' 1:053LL2097i: 20045690

SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Sig
item 4 if Restricted Delivery is desired. Agen
■ Print your name and address on the reverse X 40 v�� ► '7//❑Addr
so that we calP113turn the card to you. g R. 'wed by(P ed N e •-t=of De
III Attach this card to the back of the mailpiece, L 0/ 4 ? r lb
b,
or on the front If space permits.
D. Is delivery address different from item 1? 0 Yes
1. Article Addressed to: If YES,enter delivery address below: 0 No
Mr. Lynn Gilbert
3227 West Lakeshore Drive
3- se
Tallahassee, FL 32312 ceType
Certed Mail ❑ rasa Mail
❑Registered Return Receipt for Mercha
❑Insured Mail 0 C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Ye
2. Article Number 7002 2030 0006 8161 3362
(Transfer from s
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-1
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
• Complete items 1,2,and 3.Also complete A. Signat re-
item 4 if Restricted Delivery is desired. X Ages
• Print your name and address on the reverse X. �-t'c/�� / n d
so that we can return the card to you. B. Received by(Printed Name) C. Date• D
• Attach this card to the back of the mailpiece,
or on the front if space permits. 'E —, '1
1. Article Addressed to: D. Is delivery address different from item 1? a es
If YES,enter delivery address below: 0 No
Silver Moon Farm Inc.
1102 Gilbert Road SE 3ceType
Bolivia, NC 28422 riffled Mail CI Express Mail
❑Registered ❑Return Receipt for Merr hi
❑Insured Mail 0 C.O.D.
90r,rf.. ?T : T ; 4. Restricted Delivery?(Extra Fee) ❑Yes
(TIE 0006 8161 3379
POrm 38"1 IJ ary 44/3 Id Domestic Return Receipt 102595-02-