HomeMy WebLinkAbout15527_NC DOT & TURNER, RANDALL_19960710ZI)o z] Z7//C/rf/OC�J� s
CAMA AND DREDGE AND FILL p 5)
0�.527-e,
U
GENERAL SEP 1 1 t99i6
PERMIT
as authorized by the State of North Carolinaw��M��1�,�
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
j in an area of environmental concern pursuant to 15A NCAC'�
Applicant Name lVebur 2,c,A 4,gxlz-),4 c T r/RNc%r Phone Number
Address 0• x, l as —
City e/STY State PVC. zip d 77041 /;10S_
Project Location (County, State Road, Water Body, etc.) SA,
1-dAl t /'ce/N, cZ -n_. ,U ^A"l./ca scwo �s�-' oll f g Crj�=t/r D'r�l�✓r�s 5car,0/11. O/V Gcrr4co&e
Type of Project Activity
�50�.•9n/ 7/MdLc/2 �3lP.I,b c5 � � tq''�y� ' Gf/�'/)� �' f �'�` % ' L ci✓�i � /1i/f%/N7c�i*�A•ti'e'�" ,�' Y•f•9 t/-Q/? U.N G'�`
l�4NAL e/ivDr'�P .�1liDG� f1"4 /N_s'.7;ge eATia,✓ -F A TF.��'o,PA.t'Y .�,E"�ES '�•'t�•e �9C/�J�4Y
AU/C.✓nrCa raAfsiT1UC oAJ �P mlt /✓'T, 7
PROJECT DESCRIPTION SKETCH (SCALE: )
Pier (dock) length
Groin length
number
Bulkhead length
max. distance offshore
Basin, channel dimensions ��
r i
S9 "4 x � 30 n+ x - s�
cubic yards 3U(c
Boat ramp dimensions
Other
rFMf' , Dt5S OF 14
,4N*w4G K Wel r
This permit is subject to compliance with this application, site
drawing and attached general and specific conditions. AnyI',�/! C �''�/
violation of these terms may subject the permittee to a fine, X !U/ applicant's signature
imprisonment or civil action; and may cause the permit to be-
come null and void. /r e J 1!�;If A—
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) this pro-
ject is consistent with the local land use plan and all local
ordinances, and 2) a written statement has been obtained from
adjacent riparian landowners certifying that they have no
objections to the proposed work.
emit otticer's signature
y .T3P_
issuing date expiratio ate
attachments 711. �,_?Uo
In issuing this permit the State of North Carolina certifies that v� t,/ r�
this project is consistent with the North Carolina Coastal application fee J-0 /Jc-/CrC
Management Program.
Form D&-MP-1
APPLICATION
(To be completed by all applicants)
1. APPLICANT
b. City, town, community or landmark
Ocracoke
a. Landowner:
Name N. C. Department of Transportation
Address P.O. Box 25201
City Raleigh State N.0
Zip 27611-5201 Day Phone (919) 733-3141
Fax (919) 733-9794
b. Authorized Agent:
Name M. Randall Turner Environmental Officer
Address P.O. Box 1405
City Elizabeth Citv State N.C.
Zip 27906-1405 Day Phone (919t 331-4737
Fax _(919) 331-4739
c. Project name (if any) Oyster Creek Bridge 9 3
VOTE: Permit will be issued in name of landowner(s),
andior project name.
2. LOCATION OF PROPOSED
PROJECT
a. County Hvde
c. Street address or secondary road number
confluence of SR 1362 and Bridge Road
d. Is proposed work within city limits or planning
jurisdiction? X Yes No
e. Name of body of water nearest project (e.g. river,
creek, sound, bay) Tributary canal to Oyster Creek
3. DESCRIPTION AND PLANNED USE
OF PROPOSED PROJECT
a. List all development activities you propose (e.g.
building a home, motel, marina, bulkhead, pier, and
excavation and/or filling activities.
Removal of existing— bridge including_ support
piers. construction of new timber bridle, fill will be
placed on approaches and side slopes to dress and
stabilize slopes and to accommodate new deck elev
b. Is the proposed activity maintenance of an existinsi
project, new work, or both? both
c. Will the project be for public_ private or commercial
use? public
d. Give a brief description of purpose, use, methods of
construction and daily operations of proposed
project. If more space is needed, please attach
additional pages. Purpose: Replace functionally
obsolete bridge. Use: Public Transportation-,
Methods: Standard Bridge Replacement methods-,
Daily Operations Insress and Egress wi11 be
maintained during construction
Form DCM-MP-1
4. LAND AND WATER
CHARACTERISTICS
a. Size of entire tract N/A
b. Size of individual lot(s) N/A
c. Approximate elevation of tract above MHW or
NWL +/- 3 ft (US- GS Quads
d. Soil type(s) and texture(s) of tract
Dredge Spoil or Madeland; Sandy Texture
e. Vegetation on tract mixed herbaceous, including
Juncus sp., PhraQmites: also Yucca aloifolia
f. Man-made features now on tract soil road and
existing timber bridge
g. What' is the CAMA Land Use Plan land
classification of the site? (Consult the local land use
plan)
Y Conservation Transitional
Developed Community
Rural Other
h. How is the tract zoned by local government?
N/A
i. Is the proposed project consistent with the
applicable zoning? Yes No N/A
(Attach zoning compliance certificate, if applicable)
Has a professional archaeological assessment been
done for the tract? Yes X No
If yes, by whom?
k. Is the project located in a National Registered
Historic District or does it involve a National
Register listed or eligible property?
Yes X No
1. Are there wetlands on the site? _ Yes X No
Coastal (marsh) Other
If yes, has a delineation been conducted?
(Attach documentation, if available)
m. Describe existing wastewater treatment facilities.
n. Describe location and type of discharges to waters
of the state. (For example, surface runoff, sanitary
wastewater, industrial/commercial effluent, "wash
down" and residential discharges.) Surface runoff
from bridge and roadwav into canal
o. Describe existing drinking water supply source.
N/A
5. ADDITIONAL INFORMATION
In addition to the completed application form, the
following items must be submitted:
• A copy of the deed (with state application only) or
other instrument under which the applicant claims
title to the affected properties. If the applicant is not
claiming to be the owner of said property, then
forward a copy of the deed or other instrument under
which the owner claims title, plus written permission
from the owner to carry out the project.
• An accurate, dated work plat (including plan view
and cross -sectional drawings) drawn to scale in black
ink on an 8 1 /2" by 11 " white paper. (Refer to Coastal
Resources Commission Rule 710203 for a detailed
description.)
Please note that original drawings are preferred and
only high quality copies will be accepted. Blue -line
prints or other larger plats are acceptable only if an
adequate number of quality copies are provided by
applicant. (Contact the U.S. Army Corps of
Engineers regarding that agency's use of larger
drawings.) A site or location map is a part of plat
requirements and it must be sufficiently detailed to
guide agency personnel unfamiliar with the area to
Form DCM-MP-1
the site. Include highway or secondary road (SR)
numbers, landmarks, and the like.
SA Stormwater Certification, if one is necessary.
•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. Upon signing this form, the applicant
further certifies that such notice has been provided.
Name Ronald LM Adams
Address P.O. Box 423
Beford, Va 24523
Name Charles Francolini
Address 4 Farmin on Heights
Charlottesville, Va 22901
Name _John Maeiejczyk
Address 244 Plymouth Road
Wilmington, Del 19803
Name Dr. Charles Worth
Address 2935 West Libbv
Phoenix, Az 85023
0 A list of previous state or federal permits issued
for work on the project tract. Include permit
numbers. permittee, and issuing dates.
0 A check for $250 made payable to the Department of
Environment, Health, and Natural Resources
(DEHNR) to cover the costs of processing the
application.
19 A signed AEC hazard notice for projects in
oceanfront and inlet areas.
A statement of compliance with the N.C.
Environmental Policy Act (-N.C.G.S. 113A - 1 to
10) If the project involves the expenditure of public
funds or use of public lands, attach a statement
documenting compliance with the North Carolina
Environmental Policy Act.
6. 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
conditions and restrictions contained in the permit.
I certify that to the best of my knowledge, the proposed
activity complies with the State of North Carolina's
approved Coastal Management Program and will be
conducted in a manner consistent with such program.
I 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 «7th 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.
This is the 24 day of June , 1996
Print Name M. Randall Turner. NCDOT
Signature GJ���/ (4�z�
Landowner orAuthoried Agent
Please indicate attachments pertaining to your proposed
project.
DCM MP-2 Excavation and Fill Information
4 DCM MP-3 Upland Development
DCM MP-4 Structures Information
Y DCM MP-5 Bridges and Culverts
DCM MP-6 Marina Development
NOTE: Please sign and date each attachment in the
space provided at the bottom of each form.
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)
Timber
c. Water body to be crossed by bridge
Tributary (canal) Oyster Creek
d. Water depth at the proposed crossing at MLW or
NWL +/- 2.7 ft
e. Will proposed bridge replace an existing bridge?
X Yes No
If yes,
(1) Length of existing bridge 54 ft
(2) Width of existing bridge 10 ft
(3) Navigation clearance underneath existing
bridge +/- 5.3 ft vertical: +/- 20 ft horiz
(4) Will all, or a part of, the existing bridge be
removed? (Explain) Existing bridge to be
removed except bulkheads to be removed to
normal ground elevation
f. Will proposed bridge replace an existing culvert(s)?
Yes X 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 57 ft
h. Width of proposed bridge 24 ft clear roadway
i. Height of proposed bridge above wetlands
N/A
Will the proposed bridge affect existing water flow?
Yes X No
If yes, explain
k. Navigation clearance underneath proposed bridge
+/- 6.1 ft vertical: +/_ 19 ft horizontal
Will the proposed bridge affect navigation by
reducing or increasing the existing navigable
opening? X Yes No
If yes, explain Vertical clearance will be improved
horizontal clearance is improved since suDDorts
will be located to either side of mid -channel (ex
bridge has support in mid -channel
m. Will the proposed bridge cross wetlands containing
no navigable waters? Yes X No
If yes, explain
n. Have you contacted the U.S. Coast Guard
concerning their approval?
Yes X No
If yes, please provide record of their action.
Form DCM-MP-5
2. CULVERTS N/A
a. Water body in which culvert is to be placed
b. Number of culverts proposed
c. Type of culvert (construction material, style)
d. Will proposed culvert replace an existing bridge?
Yes No
If yes,
(1)
(2)
(3)
Length of existing bridge
Width of existing bridge
Navigation clearance underneath existing
bridge
Will all, or a part of,
removed? (Explain) _
the existing bridge be
e. Will proposed culvert replace an existing culvert?
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)
f. Length of proposed culvert
g. Width of proposed culvert
h. Height of the top of the proposed culvert above the
NT 4HW or NWL
Will the proposed culvert affect existing water flow?
Yes No
If yes, explain
Will the proposed culvert affect existing navigation
potential? Yes No
If yes, explain
3. EXCAVATION AND FILL
a. Will the placement of the proposed bridge or culvert
require any excavation below the MHW or NWL?
Yes -.-W No s pt, c/zrcusssa„
If yes,
(1) Length of area to be excavated f 5Z
(2) Width of area to be excavated 3o '
(3) Depth of area to be excavated = 37 fir/
(4) Amount of material to be excavated in cubic
yards —r 3 0 l:
b. Will the placement of the proposed bridge or culvert
require any excavation within: NIA
Coastal Wetlands _ SAVs _ Other Wetlands
If yes,
(1) Length of area to be excavated
(2) Width of area to be excavated
(3) Amount of material to be excavated in cubic
yards
c. 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 +/- 24 ft
(2) Width of area to be excavated +; - loft
(3) Amount of material to be excavated in cubic
yards +/- 22 cubic yards
d. If the placement of the bridge or culvert involves any
excavation, please complete the following:
(1) Location of the spoil disposal area
See e. and g. below
(2) Dimensions of spoil disposal area
See e. and a. below
(3) Do you claim title to the disposal area?
X Yes No
If no, attach a letter granting permission from
the owner.
Form DCM-IVLP-5
(4) Will the disposal area be available for future
maintenance? Yes No N/A
(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? X Yes No
If yes, give dimension if different from No. 2
above. See e. below
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
If yes,
(1) Length of area to be filled 2 ft
(2) Width of area to be filled 5 ft
(3) Purpose of fill backfill of bulkhead in NW
quadrant
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: NO
— 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? X Yes No
If ves,
(1) Length of area to be filled +!- 195 ft
(2) Width of area to be filled +/- 35 ft
(3) Purpose of fill raise approach grades and to
widen side slopes
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? X Yes No
If yes, explain in detail Cable TV to be attached to
bridge
c. Will the proposed project require the construction
of any temporary detour structures?
X Yes No
If yes, explain in detail 30 inch wide walkway to
allow pedestrian access to adjacent homes
d. Will the proposed project require any wort:
channels? Yes X No
If ves, complete Form DCM-MP-2
e. How will excavated or fill material be kept on site
and erosion controlled? Standard NCDOT
Erosion and Sedimentation methods and BMP's
f. What type of construction equipment will be used
(for example, dragline, backhoe or hydraulic
dredge)? Crane, Pile Driver. Backhoe Dumptrucks
rucks
and other standard 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?
X Yes No
If yes, explain in detail Bulkhead and wing walls
,will be used to stabilize fills at stream maraIns
M. Randall Turner., NCDOT
Ap llcant Project Fume
oe
Signature
June 24, 1996
Date
\Kilkenny 04
` s`t
N ols
slo94
///Sfl�\�\ S 2f� y1Y \i t yrs
New HWUnO
�Swrr Quartet Gull
/w nJ� / L \ I
K
A
\
/
C O
Sine of Kllosrattrs _
M
S /
o'
citil CAPE MATTEAAS NAT1pNAl O
3
S L A N D-
I� I
OCRACOKE
S
RECREATE
MRF.f_
E
SCALE
SCALE
0 I AVIE
fE
M
N.C.D.O.T.
DIVISION OF HIGHWAYS
HYDE COUNTY
NON -SYSTEM BRIDGE OVER
TRIBUTARY TO OYSTER CREEK
APRIL, 1996
SHEET / OF 5
REVrSEA—ic..,�J�� 9Co
H
Gap
C
Q Point
Northern.
Mary Ann .� on3j� - -- ` - /
NAT SiiASIIORIs L ,ir:� •�~ :d r\' •�'.� I�o-seper�;::• 1 C
/•_.•-pTanksl�.:`;_Polo\•�-ti_��f ,3
Coast Guard St 5 1 ��,• •l•1 • \� , � \ '. o'c •S
Lt
WindatiA I �:'':•��: ` cracoke,<- •�; �, .1 jE%�.
Point I Silver �';" � : • ' ��•
Lake y • j>i°,Y�� "`����� -""` • ter' '-_ �
I Ocracoke t,k joe_
a ; •...,• /•. Z.
Boiler •.: ���i.'•
,'•. /�,�
-
Piles. 0 6tJl . �M 2 / 4` • •.
• • f:,••
Cockle Shoal Lt Q jx :. ;•'.• _ •� /
I Pile° LS; f'. A- �% •��=wer
rN.
Springers : Alt== __ / / -'tie
!Point
l -- y
I Tenl� - +/
I� //- '� 4' C F' Ocracoke i
��•" / _ - ;, �' O Airport;
/ G
O
/ 4� ,
Teaches Hoiq, / First Grass
Channel Ltio /
iix
v
P
SCALE 1:24 000
/::• I 2 p
1 MILE
I Secom 7000 0 1000 2000 3000 4000 5000 6000 7000 FEET
ll ] 5 0 I KILOMETER
4ti1. ,
J
Coke (C)
N.C.D.O.T.
DIVISION OF HIGHWAYS
HYDE COUNTY
NON —SYSTEM BRIDGE OVER
TRIBUTARY TO OYSTER CREEK
jj APRIL, 1996
.. .. no ,rr•r
�]
f o -r 91- On
v
/�
�oNAt D' L�/Nu %4DAr„S ` O
41-3 l °
a�Feao, VA.
1 1 z4sL3 d FL I_ rAd
{ I • .. � �1 arse-s
C.Z L' —
r i3 °
0
a.o.B. FEZ. 47-A
! CrMQ1-ES �RA•1teL�u1 { G
Z q �aeMrvcTe� f16isMrs ,,,��_ I
n H n \ C�/Ak�e7rEtvr«c� VA. Gy.D•�
`EX. Bu ��LN EAJ
Eo
1
i
�•jNTI �Iw µ
�1�1L IJ�►rL�
JOr+�1 MAEI8,7'-zY
4 PL--1M 1114 RD.
I,U,un,�c �e,�.►, i�E f���� E
IAp-� -> ae EXc,AvA-r--D
• So 2S o so
/"-Soy
9 J oo /ofoo/r-oo
-STA la +Z-' -7
3 19 �--r'M �Q1DGE
B 21 DG C S C">i-T E,L . -a
f��aPoSsD � Cj•Q1+oe
EX�StiN� ¢
1`I GZ-.r
I
�b
ELEV. =S9•S---)
Ey�•s-n,�� �osrs
�-W5 l EL. = 94 •`7
417-/ 9C. 11.11 Am
Imo- QoPoSe� ��t�'S
PaSED � G,2nnE
LT
•
i� A p_E A --I,, 'Sc- M 14 L.-)
4366 -,?�cu.yDS.
EL�V4Tio>\15 P-- Assu r-, EO
//o
/,0 0
5p LT � SD I �f
Rl3�E
/0314
/66
SrP, 9 +75
So L-7- 5o et
I
'P(Z0 p oS E.7 Ce . 6 (LADE
EC.=A3.o
N
STA /0 +_7 8
!�-CEVArio 15 APLE A5Surlc0 1�l�-r'u M
N.C.D.O.T.
DIVISION OF HIGHWAYS
HYDE COUNTY
NON -SYSTEM BRIDGE OVER
TRIBUTARY TO OYSTER CREEK
APRIL, 1996
SHEET'5 OF 'S
'REVI.e'cb Su�lEI 9%
STATE OF NORTH CAROLINA
DEPARTMENT OF RANSPORTATION
JAmEs B. HUNT JP_
GOVERNOR
Mr. John Maeiejzyk
244 Plymouth Road
Wilmington, Del. 19803
Dear Landowner:
DIVISION OF HIGHWAYS
P.O. Box 1405
Elizabeth City, N.C. 27906-1405
Phone: (919) 331-4737
Fax: (919) 331-4739
June 24, 1996
'Sa4l ��,t a t.
C%� ckX,., bC
GARLAND B. GARRETT JP_
SECRETARY
The North Carolina Department of Transportation (NCDOT) is proposing to replace the
third bridge over a tributary canal to Oyster Creek at Ocracoke, North Carolina. The old bridge
is functionally obsolete. The work proposed will result in incidental impacts to one or more
designated Areas of Environmental Concern (AEC's), and therefore will require authorization
from the Division of Coastal Management in accordance with the Coastal Area Management
Act (CAMA).
The attached form is submitted to insure that adjacent; riparian landowners have an
Opportunity to review and comment on the proposal. Please review the attached material at
your convenience and, if you have no objections to the project, please return the form with your
response within 10 days to this office. No response from you within 10 days following receipt
of this communication will be construed to mean you have no objections. If you do have
objections to the project, please forward your comments to:
Mr. Terry Moore, District Manager
Division of Coastal Management
N.C. Department of Environment; Health
and Natural Resources
1424 Carolina Avenue
Washington, N.C. 27889-2188
Thank you for your cooperation.
Sincerely,
M. Randall Turner, Division Environmental Officer
Planning & Environmental Branch -Division 1
Attachments
cc: Mr. Terry Moore, Division of Coastal Management
RE
ADJACENT RIPARIAN LANDOWNER STATEMENT
(Hyde County: Oyster Creek Bridge Replacement)
General Statute 113-229 requires that riparian landowners with property
adjoining a proposed development in an Area of Environmental Concern be given ten
(10) days in which to comment on the proposed development. This form allows the
adjacent riparian landowner to express either: (1) that he objects to the project; or; (2)
that he does not object and desires to waive his/her right to the 10-day period so that
the processing of the application can progress more rapidly. Of course, the adjacent
riparian landowner need not sign this form at all if he/she so chooses. No response
within 10 days following receipt of this letter and form will be construed to mean the
adjacent riparian landowner has no objections.
i; am an adjacent riparian property owner
and am aware of the North Carolina Department of Transportation's plans for replacing
the third Oyster Creek Bridge on Ocracoke in Hyde County. I am further aware that this
work will occur in one or more AEC's and therefore will require authorization from the
Division of Coastal Management in accordance with CAMA.
1 have no objection to the project as presently proposed and
hereby waive that right of objection as provided in General
Statute 113-229
I have objections to the project as presently proposed and
my comments are attached
Signature of Adjacent Riparian Landowner
Date:
SENDER:
o
■Complete hems 1 and/or 2 for additional services.
I also wish to receive the
n
■Complete hems 3, 4a, and 4b.
following services (for an
°n
■ Prim m your name and address on the reverse of this form so that we can return thus
extra fee):
s
card to you.
■Attach this forth to the front of the mailpiece, or on the back if space does not
1. ❑ Addressee's Address
V
p
permit.
■Write'Retum Receipt R
p equested' on the mailpiece below the article number.
2. ❑ Restricted Delivery
W
■ The Return Receipt will show to whom the article was delivered and the date
e
delivered.
Consult postmaster for fee.
a
3. Article Addressed to:
4a. A Number
d
I
FL
/sir ..io h N /Yb eie t zc� fs
��`� / �� A7/ L �
E
o
M
��� t'ly��a
4b. Service Type -
d
o
G�
Registered ' Certified
❑IM
a:(�r
�/�7//iY�( '� /p
9803
❑ ❑cm
Express Mail Insured
E
u
g 'Retum Receipt for Merchandise ❑ COD
in
_
7. Date of Delivery
G�
<
o
5. �eceived By: (Print Name)
8. Addressee's Address (Only if requested
u
c
D
r
A
PS Fort 00 r 1, vecrornuer 1Z1y4
...,,,,..,,., ..-.-,n Receipt
I
SENDER:
;o
■ Complete items 1 and/or 2 for additional services.
I also wish to receive the
■Complete items 3, 4a, and 41b.
■ Print your name and address on the reverse of this form so that
we can return this
following services (for an
extra fee):
j
card to you.
■Attach this form to the front of the mailpiece, or on the back it
space does not
1. ❑ Addressee's Address
d
c,
permit.
■Wnte'Retum Receipt Aequested'on the mailpiece below the
article number.
2, ❑ Restricted Delivery
■The Return Receipt will show to whom the article was delivered
and the date
o
delivered.
Consult postmaster for fee.
3. Article Addressed to:
4a. le Numb
a
Mr. CJAr,�s FrR.►z o/,v�'
S/ %� C' / &
0
4/ �Ar/%��/(�fA.C� �7t �L',l�
7
4b. Service Type
❑Registered
to
��/l��
ertified
❑ Express Mail
w
�$ f vC!� oZc�9d /
El Insured
nw,/
Return
o
[3Receipt for Merchandise COD
a
7. Date of Delivery
�
� -?- 07
5. Received By: (Print Name)
8. Addressee's Address (Only if requested
and fee is paid)
6. Signatur d r Lssee or Agent
I•
i.
l A-11
PS Ftam December 1994 Domestic Return Receipt
�ItNUtti:
■Complete items 1 and/or 2 for additional services.
I also wish to receive the
v
SENDER:
■ Complete items 3, 4a, and 4b.
following services (for an
v
■ Complete items 1 and/or 2 for additional services.
I also wish to receive the
■ Print your name and address on the reverse of this form so that we can return this
extra fee):
■Complete items 3, 4a, and 4b.
following services (for an
card to you.
d
■ Print your name and address on the reverse of this form so that we can return this
extra fee):
this form to the front of the mailpiece, or on the bac if space does not
1. ❑Addressee's Addr@SS
card to you.
it
permit
>
■ Attach this form to the front of the mailpece, or on the back if space does not
1. El Addressee's Address
Wdte'Retum Receipt Requested' on the mailpiece below the article number.
2. El Restricted Delivery
E,
ppermit.■
■The Return Receipt will show to whom the article was delivered and the date
a
a,
■ Write'Retum Receipt Requested'on the mailpiece below the article number,
2• ❑ Restricted Delivery
delivered.
Consult postmaster for fee.
■The Return Receipt will show to whom the article was delivered and the date
3. Article Addressed to:
RaNiliZnl 4N,U &411; '57
P• o . fox �a-3
Received By: (Print Name)
6. Signatu : (Addressee or Agent)
n ,
PS Form 3811, December 1994
_N
v
C delivered. Consult postmaster for fee.
4a. Article Number a)o
p a: o 3. Article Addressed to: 4 cle Number
Q 72 50! /��
4b Service Type
•
❑ Registered Certified
¢
a
o
n
'��� f/
21-sc
J
❑ Express Mail ❑ Insured
S
Cn
f �1F�c��X
�1F�
El Return Receipt for Merchandise El COD
:3W
7. Date of Delivery Q
8. Addressee's Address (Only if requested
and fee is paid)
t
ir
5 R ed By: Print Name)
3
6. gignaAddressee or Agent)
i.
X
Domestic Return Receipt
T
PS Form 3811, December 1994
4b.Gervice Type
440-
��
- 'F g Istered I/ -6 rtified
4 `r
Ex »ass Mail ❑ Insured
�tUrn
Receipt for Merchandise ❑ COD
1, Date of Deliv
8. Addressee's Address
and fee is paid)
if requested
c Return Receipt