20040981 Ver 1_COMPLETE FILE_20040617

P@20MR,
JUN 2 2 2005
WETLAN S AND STOR W TERIBRANCH
1127 Alspaugh Dam Road
Taylorsville, NC 28681
June 15, 2005
401/Wetlands Unit
NC Division of Water Quality
1650 Mail Service Center
Raleigh, NC 27699-1650
Subject Property: 645 Sam Poole Road, Crescent Land and
Timber Subdivision, Lot #263, DWQ #04-0981
Dear Sirs:
All Work has been completed on the above referenced
Project. I am enclosing the Certificate of Completion as
requested.
Sincerely,
elen S. ammer
HSH/hsh
Enclosure
Certificate of Completion
DWQ Project No.:
04-0981
County: Alexander
Applicant: Helen S. Hammer
Project Name: 645 Sam Poole Road, Crescent Land & Timber Subdivision, Lot #263
Date of Issuance of 401 Water Quality Certification: July 27, 2004
Upon completion of all work approved within the 401 Water Quality Certification and Buffer Rules, and any
subsequent modifications, the applicant is required to return this certificate to the 401/Wetlands Unit, North
Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699-1650. This form may be
returned to DWQ by the applicant, the applicant's authorized agent, or the project engineer. It is not
necessary to send certificates from all of these.
Applicant's Certification
I, Helen S. Hammer , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature: Date: June 15, 2005
Agent's Certification
I, , hereby state that, to the best of my abilities, due care and
diligence was used in the observation of the construction such that the construction was observed to be built
within substantial compliance and intent of the 401 Water Quality Certification and Buffer Rules, the
approved plans and specifications, and other supporting materials.
Signature:
Date:
DGC?C?p?If? p
D
JUN 2 2 2005
DENR - WATER QUALITY
If this project was designed by a Certified Professional WETLANDS AND STORMWATER BRANCH
I, , as a duly registered Professional (i.e.,
Engineer, Landscape Architect, Surveyor, etc.) in the State of North Carolina, having been authorized to
observe (periodically, weekly, full time) the construction of the project, for the Permittee hereby state that,
to the best of my abilities, due care and diligence was used in the observation of the construction such that
the construction was observed to be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plans and specifications, and other supporting materials.
Signature: Registration No.: Date:
A ?
RCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor
July 27, 2004
Helen S. Hammer
1127 Alspaugh Dam Road
Taylorsville, NC 28681
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
DWQ Project # 04-0981
Alexander County
Subject Property: 645 Sam Poole Road, Crescent Land & Timber Subdivision, Lot # 263
Approval Of 401 Water Quality Certification And Authorization Certificate per the Catawba River Buffer
Protection Rules (15A NCAC 2B.0243) with Additional Conditions
Dear Ms. Hammer:
You have our approval, in accordance with the attached conditions and those listed below, to place fill within or
otherwise impact approximately 0.006 acres of waters and 600 squard,feet (ft) of protected riparian buffers for the
purpose of installing rip rap to stabilize approximately 150 feet of shoreline, as described within your application
dated April 14, 2004 and received by DWQ on June 17, 2004. After reviewing your application, we have decided
that the impacts are covered by the N.C. Division of Water Quality (DWQ) General Water Quality Certification
Number(s) 3373 (GC3373). The Certification(s) allows you to use Regional General Permit No. 198200030 when
issued by the US Army Corps of Engineers (USACE). This letter shall also act as your approved Authorization
Certificate for impacts to the protected riparian buffers per 15A NCAC 2B .0243. In addition, you should obtain or
otherwise comply with any other required federal, state or local permits before you go ahead with your project
including (but not limited to) Erosion and Sediment Control and Duke Power regulations and permits. Also, this
approval to proceed with your proposed impacts or to conduct impacts to waters as depicted in your
application shall expire upon expiration of the 404 or CAMA Permit.
This approval is for the purpose and design that you described in your application. If you change your project, you
must notify us and you may be required to send us a new application. If the property is sold, the new owner must be
given a copy of this Certification and approval letter and is thereby responsible for complying with all conditions.
This approval requires you to follow the conditions listed in the attached certification and any additional conditions
listed below.
The Additional Conditions of the Certification are:
1. Impacts Approved
The following impacts are hereby approved as long as all of the other specific and general conditions of
this Certification (or Isolated Wetland Permit) are met. No other impacts are approved including incidental
impacts:
Amount Approved
(Units) Plan Location or Reference
Shoreline 150 (feet)
Waters 0.006 (acres)
Buffers 600 (square ft.)
401 Wetlands Certification Unit
1650 Mail Service Center, Raleigh, North Carolina 27699.1650 One
2321 Crabtree Boulevard, Suite 250, Raleigh, North Carolina 27604 NofthCarolina
Phone: [phone] /FAX [phone] / Internet: http://h2o.enr.state.nc.us/ncwetlands Naturallm
Helen Hammer
Page 2 of 2
July 27, 2004
2. Diffuse Flow
An additional condition is that all stormwater shall be directed as diffuse flow at non-erosive velocities
through the protected stream buffers and will not re-concentrate before discharging into the stream as
identified within 15A NCAC 2B .0243(5).
3. Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer
Rules, and any subsequent modifications, the applicant is required to return the attached certificate of
completion to the 401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center,
Raleigh, NC, 27699-1650.
Violations of any condition herein set forth may result in revocation of this Certification and may result in criminal
and/or civil penalties. The authorization to proceed with your proposed impacts or to conduct impacts to waters as
depicted in your application and as authorized by this Certification shall expire upon expiration of the 404 or CAMA
Permit.
If you do not accept any of the conditions of this Certification (associated with the approved wetland or stream
impacts), you may ask for an adjudicatory hearing. You must act within 60 days of the date that you receive this
letter. To ask for a hearing, send a written petition, which conforms to Chapter 150B of the North Carolina General
Statutes to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, N.C. 27699-6714. This
certification and its conditions are final and binding unless you ask for a hearing.
Any disputes over determinations regarding this Authorization Certificate (associated with the approved buffer
impacts) shall be referred in writing to the Director for a decision. The Director's decision is subject to review as
provided in Articles 3 and 4 of G.S. 150B.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act and the
Catawba riparian buffer protection rule as described within 15A NCAC 2B .0243. If you have any questions, please
telephone John Dorney at 919-733-9646 or Bob Zarzecki at 919-733-9726.
AWK/bs
Enclosures: Certificate of Completion
GC 3373
Catawba Buffer Fact Sheet
Sincerely,
. (_?? /4-
Alan W. Klimek, P..
cc: Duke Power Lake Management, PO Box 1006, Charlotte, NC 28201-1006
USACE Asheville Regulatory Field Office
DWQ Mooresville Regional Office
File Copy
Central Files
Filename: 04-0981 Helen Hammer (alexander) 401
DUKE POWER LAKE MANAGEMENT, EC12-Q
P O BOX 1006
3 C?ARLOTTE, NC 28201-1006
704-382-1567 or TOLL FREE 1-800-443-5193
t.-
APPLICATION FOR PERMIT TO STABILIZE THE SHORELINE IN NORTH CAROLINA
i
Please type or print and fill in all blanks. If information is not applicable, so indicate by placing N/A in blank. PLEASE
SUBMIT APPLICATION AND APPROPRIATE DUKE POWER FILING FEE, PAYABLE TO DUKE POWER, TO
ABOVE ADDRESS. I. Applicant Information 040981
A. Name S, Ka r?? vr? c i?
B. Mailing Address /f, Z,!z Q y A Lem &L.1- lS' << 2 f
C. Telephone:'
II. Location of Proposed Project
A. Lake ' t- y
B. Street Addresslr#,S , 4) )m P/y, ?L 2Cbt i 1 /`Lf V i ?/ ?(; ,2 S/v !
i
C. County 4 /c-- JLl ti
D. City, town, community or landmark , > Y. y
E. Section ?,Ak,, Lot # z? Subdivision C? r r- S c c n ,??4- %
F. Directions to property by road f /y m kl'fl K 1-2J h,- 3r-oro Y 6A Sam PI l I,--
1A C" A t,:,- d. C -r7 l e :e 7 c'rc yrL'I I( bo r
G. Latitude and longitude for the project site
H. Please submit a map showing the coordinates or a detailed map (USGS quad map, city map, etc.) showing the
exact location of the project site. (NOTE: Latitude/ longitude coordinates can be found c: rii. . i .
www.niapsontis.coni. Directions: Don't register, click "Maps", enter address, draw map, select "Map
Clicking Will...", select "Lat/Long", click map)
Ill. Description of Project _ J01 WETLANDS/401 GROUP
A. Length of wall
B. Material << I a ?? 1UN
C. Distance from property line/shoreline 0 ? T1 D/?.?' 44 v1{1= Z?p?
IV. Intended Use of Project Area
A. Private I
B. Commercial
WATER QUALITY SECTIgAr
V. Applicant Signature Date -2
PLEASE NOTE THE FOLLOWING:
• A COPY OF THE COMPLETED APPLICATION WITH A ROAD MAP SHOWING LOCATION OF THE PROPERTY
MUST BE SUBMITTEM 'I'O: U.S ARMY CORPS OF ENGINEERS, 151 PATTONAVE. - ROOM 208,
ASHEVILLE, NC 28801-5006
• A COPY OF THE "DUKI: POWER APPLICATION FOR PERMIT TO STABILIZE TIIE SHORELINE IN NORTH
CAROLINA" AND SEVEN (7) COPIES OF TI{E COMPLETED "NC DIVISION OF WATER QIJAI.I"IY PRE-
CONSTRUCTION NOTIFICATION APPLICATION" MUST BE SUBMITTED WITH THE DIVISION OF WATER
QUALITY APPLICATION FEE TO:
NC DIVISION OF WATER QUALITY
ATTENTION: JOHN DORNEY
PARKVIEJV BLDG., 2321 CRABTREE BLVD.
RALEIGH, NC 27604
919-733-1786
10 1r,u-'?.h

B[O-ENGINECIUNG AND SHORELINE STAB[[ZAT[ON MIT[GATION
TECHNIQUES
FOR LAKCS MANAGED B1' DUKE PONVER, LAKE MANAGEMENT
1. Bio-engineering
A. Definition
Bio-engineering is an effective scientific method, using a combination of natural and living
materials, to stabilize eroded banks along the shoreline. Bio-engineering techniques vary
according to a number of factors, including but not limited to; slope, soil type and wave action.
Often a combination of techniques may be utilized to most effectively control erosion in areas
with varying conditions.
B. Benefits
In addition to controlling erosion, and the aesthetic value of a more natural shoreline, the use of
native plants create additional liabitat for wildlife. A permit and written authorization for any
shoreline stabilization project is required from Duke Power, Lake Management. By utilizing bio-
engineering as (lie primary stabilization tcchnique, the permit application fee for shoreline
stabilization is waived.
C. Native Plant Species
COMMON NAME SPECIES

SOFT RUSH JUNCUS EFFUSUS
AIUZO\\' ALUM PETANDRA VMGIN[CA
SIIA1,LOW SI'DGE CARER LUIUDA
SILKY DOGWOOD CMNUS AMOMUM
'T'USSOCK SEDGE CA[ZL.X S'I'R[C`f'A
BUITONBUSI{ CEPIIALANTIIUS OCCIDENTALIS
GRAY DOGWOOD CORNUS IZACEMOSA
YELLOW I[ZIS IRIS PSEUDACORUS
VMGIN[A BLUE-F[-AG IRIS V[RGINICA
SOFT RUSH JUNCUS EFFUSUS
P1CKI IZI:L\\?EED PONTEDEMA CORDATA
Bl-ACK \VILI,OW
T SAUX NIGRA
?
SOI I
STEM BUI'RUSI{
GItGI:N BUI,RUSI{ SCIIZI'US VALIDUS
-SCIRI'US A"1`ROVIIZI:NS --
_ ____ f=l l (.;LASS -
-- -- - - VALLISMI RIA AMERICANA
\V?OOL?;pASS
. .-?". •,,,.._. ?,..?... .,?..-..?.,, ???,?? ni?? inn u.??.-u uia)' ?11SU Ue aCCCI)(81)IC. Plant ;I)CCIC i (hat all' not
native (o Duke. I'mv(-r IaI ? ?, ;liould not h(? considered and will not likcly 1w appfovcd.
" I I " , , .' /PP)

(,?T'I'ACt t n t t:?T
D. Techniques
Bio-engineering techniques normally include minor grading to allow for the installation of a rip
cap toe, rock gabion, Bio-log®, crib wall or similar structure in high energy areas. The structures
are then enhanced by the addition of naturaUliving material. For example:
1. live stakes - branches cut from living material and planted with stems and buds pointed
upward. Initially they offer little to no soil reinforcement but do so after the first growing season
once a root system becomes established. Often used with other techniques and conducted during
the donnant season.
2. live fascine - branches bundled and secured together and placed in a very shallow trench
along the toe of the eroded bank or in the bank face. They are usually installed in conjunction
with geotextile fabrics above a rip rap or gabion toe.
3. brush mattress - includes both live stakes and live fascines. Provides protection of the
shoreline upon installation and can be used in layers beginning just above a rip rap or gabioti toe.
4. plant plugs - plantings with intact root stock. Placed directly into the bank face with (Ile
soil compacted around the root stock.
G. Follow up activities
Riparian Zone Management Information: Duke Power will design and publish an iuformational
piece that will provide property owners with a range of information about bio-engineering
techniques, material sources, infornation sources and the value of riparian zones. This will be the
final project in the Riparian Zone Management Initiative and will serve as a compilation of the
oil-going efforts through the year 2000.
II. Mitigation
A. General guidance
Mitigation proposals should provide realistic but substantial allowances for reducing and
relieving the impact of the proposed shoreline stabilization technique proposed. [n general,
mitigation activities should enhance the wildlife habitat in the immediate area of the stabi117-atiotl
activity and may consist of, but are not limited to; enhancing fish cover under an approved pier or
similar structure, mainlairrirrg a natural vegetative buffer along; (lie entire shoreline of (lie lot,
placing or maintaining secured cover and perching habitat (e.g. root wads, stumps, fallen trees,
etc.) along; portions of the shoreline.
its
(ATl'ACll',((:,T 91
13. Rcvicw Timcfralnc
Applicants for proposed s(torcline stabilization activities identified in the Shoreline Stabization
Technique
Selection Criteria (Attachment 1) that require wildlife agency review and/or mitigation must send
their applications to the district game and fisheries biologist of the applicable NC/SC agency for a
minimum 30-day review and comment period. In the absence of any findings of significant
adverse impacts on fish and wildlife resources during this 30-day review period, the applicant
will be allowed to proceed without further notice to send their completed application to Duke
Power-Lake Management for approval. If there are findings of significant impact and those
impacts are not adequately mitigated, then the applicant will not be allowed to proceed with the
proposed stabilization activity. Applicants should make every effort to comply directly with
resource agency recommendations.
C. Agency Review
Lake (NC) JAMES, RHODHISS, (SC) WYLIE (SC) (SC) C•ISHING CRK., GREAT
LOOKOUT SHOALS, NORMAN, FALLS/ROCKY CRK.,
MTN. ISLAND, WYLIE (NC) WATERE•E, KEOWEE,
JOCASSEE, GASTON SHOALS,
99-ISLANDS
Agency MR. CI{RIS GOUDREAU MR. DICK CI{IUSTIG
NT
F MR. RON AHLL
SC DEP
ENT OF
RT
NC WILDLIFE RESOURCES O
SC DEPARTME A
M
Contact COMMISSION NATURAL RESOURCES NATURAL RESOURCES
RT. 6, BOX 685 PO BOX 4496 PO BOX 167
N{ARJON, NC 25752-9229 ROCK HILL, SC 29732 COLUMBIA, SC 29202
*Applicants should fill out the Duke Power Shoreline Stabilization Application form completely,
attach any applicable mitigation proposals and send along with a cover letter to the agency
contact.
Agency colTespondence must also be attached before sending the final application proposal to
DUke Power for approval.
; •,,•
Attacllntcat I '
Shoreline Stabilization Technique Selection Process
Shoreline Stabilization I Project area
Application \ classification
alas dassification is the bank heig
based on shallow > =1 foot?
water criteria?
Applicant can use
hardening structures.
" Applicant can only
use bioengineering or
rip rap. Seawalls not
allowed.
Is the bank
height > = 5ft?
Applicant can use
hardening structures.
Mitigation requirements
determined by stale
wildlife agency.
Stabilization not
allowed
No abifvation allowed in
IMz from March - June to
limit Impacts to fish spawning.
Req ices state wildlife agency
(e.g. NCWRC, SCONR)
re ' and approval.
Applicant must use
bioengineering stabilization.
Mitigation requirements
determined by state wildlife
gency. Seawalls not allowed.
General conditions:
All seawalls must have rip-rap at base.
-Considedng current lake level operating targets and variability and the desire to prevent unnecessary impacts, rip
rap must be confined to the area between G' below full pond elevation and full pond elevation to the maximun)
practicable extent. Potential exceptions indude areas wliere entire placement is above the F[=RC projed
boundary, where bangs are already eroded above the full pond elevation or where severely eroded banks must be
sloped back or terraced to provide minimum bank, stability.
-The bank height is the average height of the eroded shoreline( measured lion) tho original I:)f.e bed I') the top of the
eroded bard:) io the area to be stabilized.
-Bioengineering tediniques within an lfAZ require applicant to provide photo evidence of suCC,' s ;ful vo(A"lotion
r.stablishment at 1 year point. Bioengineering is a stabilization approadi that uhl2e', natural and living material.
Bioengineering techniques include use of rip rap with live stakes, rod: tilled gabions, live Staked Glit) Wr111s, biology,
and nunutrous other adivilwr ,
-Applicant can UGC bioengineering, rip rap, seawalls or any combination of Slabilizahon todlfltgw,:, wlI''It! use of
hardcr)ing stnxlures arc all,)?:ed
-Slabilvahon in an IW17 req?rirr ; rcnsona(,le mitiy3tion requiwmetil:-, a; deten111n-N1 tlu?,u<;h ?:nn ,ull:it??nr v:itb :,tat.'
-`,;tabilization io areal dassih??d ay rdatwal due to the presen(i] of s1911ilr,'10 cnlUn:il r??sour?:?r-. bout f n,)t 1):)vu
,)rlifacty inl[mr-1 J by uUlizinq any sbor htw stabilization tedinigtVe
r,l?ril 1999
BANK HEIGHT DETERMINATION
FOR SHORELINE STABILITATION ACTIVITIES MAY, 1999
g

I
State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
September 25, 2000
Jimmy Chisholm
Cai;olina Power and Light Company
179 Tillery Dam Road
Mt, Gilead, NC, 27306
And
Jol-, Hall
Duke Power and Lake Management
P.O. Box 1006
Charlotte, NC, 28201-1006
R,-.: General 401 Water Quality Certification for Lake and Reservoir Activities
Dear Messrs. Chisholm and Hall:
The purpose of this correspondence is to clarify the provisions and process relative to NC
Division of Water Quality's General 401 Water Quality Certification Number 3280 which correspond to
the U.S. Army Corps of Engineers General Permit 198200030. We understand that you receive
numerous requests from lakefront property owners inquiring about the permit requirements for activities
they propose to conduct on the waterfront. After you have determined the property owner needs to
obtain a permit for dredging or shoreline stabilization from you, we understand they are then instructed
to obtain the necessary 404/401 Permits. These property owners should pursue the following sequence
of events to determine their 404/401 permit needs. We have coordinated this letter with the U.S. Army
Corps of Engineers so that it relates equally to both permitting programs.
The U.S. Army Corps of Engineers is the lead agency and accordingly determines 404 requirements
for all projects. Applicants should first contact the appropriate Corps field office representative for
their county. To identify which counties are handled by a particular Corps regulatory field office or
to find the appropriate individual in the regulatory staff, the public can access the Wilmington
District Regulatory Homepage at www.saw.usace.army.mii/wetlands/regtour.lltm or read from the
list on Appendix A. The Corps staff will determine if a 404 Permit is required, and if so, which
particular one. It is important that the applicant learn specifically which Nationwide or Regional
General Permit applies to their work. For lake and reservoir activities, General Permit 198200030
(also called General Permit 30 or Gl' 30), is often the appropriate permit. The matching General
Certification for GP 30 is the subject of this correspondence.
2. Application for GP 30 involves submittal of detailed plans, location maps, and other supplemental
information cxplaininl; the nature and scope of the %N,ork to the Corps. If the work is determined to
comply with all conditions of GP 30, the Corps will then issue a" tear sheet" to the applicant, culler
on-silt or by mail, that qualifies as the Corps' written confirmation that the proposed wort: complies
with this regional gencral pcrlrlit. It is important for applicants to note that (;I' 30 always requires
written concurrence hoill tic Corps.
Nun t)c,charge Dranch 2321 CrabCreu lil_vd Parkvicw Raleigh. North Carolina 27604>-
1ra(,phonc919-733-178G Bldg FAX a 733 9-959
/n (pawl (){)(.c> U"y Afl,inl111-0 l?drx? (n?ik>y c? ?pY. icc:yc?crv 10'X rxxt ?.nn sun rti (?.i(r`r

If the Corps tells an applicant that no 404 is required for their project, then no 401 Certification is
required. However, applicants should note that projects located within the Neuse River, Tar-Pamlico
River, or Randleman Reservoir Basins may require approval of Buffer Rules for projects within
these watersheds. In such cases, the applicant should call the appropriate DWQ Regional Office
staff (Appendix B) to discuss the project. The Regional Office staff may elect to perform a site visit
to review the site conditions and discuss the buffer approval or variance process.
4. If the Corps requires a 404 Permit, then a 401 Water Quality Certification is required. In the case of
GP 30, DWQ has a matching General Certification (GC 3280), which is attached. The first thing the
applicant should do is carefully read GC 3280 to determine whether written concurrence is required.
Written DWQ concurrence is required if the activity involves any fill, dredging or excavation of
waters or wetlands. This includes any waterward extension of the shoreline, excavation of boat
basins (even during lake draw-down periods), bank stabilization practices that involve any new fill in
waters (including any amount of new rip .rap placement), boat ramps involving placement of fill in
waters, and new dredging. Activities which do not require written concurrence for GC 3280 include
seawall repairs that do not require any new fill in waters, and the placement of pilings for docks,
piers and boathouses. It is vital that the applicant understands the difference between "No 401
Required" versus "No Written Concurrence for the 401 Required." No 401 is required only if no
404 is required. If a 404 is required, a 401 is always required. If the scope of work falls below the
thresholds for written concurrence on the 401„ the conditions of GC 3280 still apply, and the
applicant does not have to submit a formal request for approval from DWQ for their specific project.
However, the applicant is still required to follow all of the conditions of GC 3280, which you can
copy for them or they can download from our web site. A speed limit sign is a useful analogy to
explain this - a driver needs to look for and obey the speed limit sign on a road, but does not have to
obtain a letter from a police officer saying lie has permission to drive down the road.
If a project does require written concurrence for GC 3280, then the applicant must provide a written
application to the Division of Water Quality. We have prepared a special link entitled "A Lake
Diveller's Guide to the 401 [Water Quality Certification Process" on the 401/Wetlands Unit web site
at http://112o.enr.state.nc.us/ncwctlands . This site contains information to guide the applicant
through this process, including links to the Pre-Construction Notification (PCN) application form.
Copies of the appropriate web pages are attached herein for you to provide to applicants without
internet access. If the applicant has already filled out a PCN form for the Corps, they can simply
copy this PCN form for DWQ. In brief, the applicant is required to provide seven copies of the PCN
form, an application fee made out to the Division of Water Quality ($200 if total impacts fall below
I acre of waters/wetlands and 150 linear feet of streams, $475 if above these thresholds), and good
quality vicinity and local maps depicting the impact. The reason we require seven copies is that we
act as a state clearinghouse, and provide copies to five other agencies, which saves the applicant
from this requirement. Provided that the applicant has included all of the required information,
applications such as these are quickly issued by DWQ. The GC 3280 applications that are placed on
hold are usually deficient in maps. Applicants can save themselves time by preparing good maps
with scales and north at-rows. The vicinity niap must clearly depict their property within the county
or city. The site rnap must clearly show their property boundaries, and the location, nature and
extent of the impacts. USGS topo malls are typically the most useful type of site map for individual
property owners to use as a base for their site map. Impacts must be quantified on the snap and in the
form as an area (i.e. 0.5 acres, not just shoreline length). If an applicant needs help filling out the
application form, they should contact the appropriate DWQ Regional Office Staff, or Cyndi Karoly
at [phone] in the DWQ Central Office.
Thank you for your attention. If you have any questions, plcasc telephone lolui 1)orncy at 919-733-
9646 or Cyndi I:aroly at [phone].
Sincerely,
lohn Dorsey

The Basics of the 4ul water wucimy ""I UA %J
401 Water Quality Certification Program - The Basics
Section 401 of the Clean Water Act delegates authority to the states to issue a 401 Water Quality
Certification for all projects that require a Federal Permit (such as a Section 404 Permit). The "401" is
essentially a verification by the state that a given project will not degrade Waters of the State or
otherwise violate water quality standards. The following is a basic outline of the 401 review process in
North Carolina: -
When do you need to request a 401 Water Quality Certification?
If the U.S. Army Corps of Engineers determines that a 404 Permit is required because your
proposed project involves impacts to wetlands or waters, then a 401 Water Quality Certification is also
required. The Corps also determines which type of permit is applicable to your work, a Nationwide,
Regional, Generalor Individual Permit. For each of the Nationwide, Regional or General Permit, a
matching General Certification must be issued by DWQ in order for the Permit to be valid. An Individual
401 Water Quality Certification is necessary if an Individual 404 Permit is required. Once the Corps has
determined which type of permit you should request, you can read the matching General Certifications
on the DWQ web page. Please read the applicable Certifications very carefully, and note whether or no
written concurrence/notification is required by DWQ. If written concurrence/notification is not required,
and your project meets all of the conditions of the General Certification, you do not need to submit a
formal application or receive a signed 401 Water Quality Certification for your particular project. If the
General Certification states that written concurrence is necessary, please note the following steps
necessary to obtain your 401 Certification.
Fill out a Pre-Construction Notification
in North Carolina, you use a single form to request both a 404 Permit and 401 Certification. This
PCN Form can be downloaded directly. Please note, this form will be revised later in 1999 when the
final versions of the new Nationwide Permits are issued. Just follow the instructions on the form. You
should also include a cover letter explaining your project, and enclose a vicinity map and a site map (t(
scale) depicting all the proposed impact areas. You are also encouraged to provide any supporting
documentation available, such as correspondence received from the Corps of Engineers or
photographs. Remember, the more clearly you describe your project, the more quickly we can review
your application. You will need to submit this application to the Corps and provide seven copies of the
entire application to DWO. If you do not provide seven copies, your application will be retumed as
incomplete. DWO will distribute the copies to five other state agencies, as well as the appropriate DW
regional office, which saves you time and expense.
WATEP, `QUALITY P1_. 44ING Fax:[phone] may 15 '01 10:05 P. 02/04
LAKE AND RESERVOIR ACTIVITY CERTIFICATION
GENERAL CERTIFICATION FOR PROJECTS ELIGIBLE FOR CORPS OF
ENGINEERS REGIONAL PERMIT NUMBER 19820030 (TVA OR FERC
REGULATED PUBLIC tTTILITIES) AND REGIONAL. PERMIT 198200079 (COE
LAKE AND RESERVOIR MAINTENANCE REPAIR AND CONSTRUCTION
ACTTVITIES) AND NEUSFJTAR-PAMLICO/RANDLEMAN BUFFER RULES.
This General Certification is issued in conformity with the requirements of
Section 401, Public Laws 92-500 and 95-217 of the United States and subject to the
North Carolina Division of Water Quality Regulations in 15A NCAC 2H, Section .0500
and 15A NCAC 2B .0200 for the discharge of fill material to waters and wetland areas
as described in the Wilmington District's Regional (General) Permit Number 198200030
and Regional Pem-dt Number 198200079 and for the Neuse, Tar-Pamlico and Randleman
Buffer Rules (I SA NCAC 213 .0233-029) and.0250). This Certification replaces Water
Quality Certification (WQC) Number 2674 issued on January 21, 1992 and Water
Quality Certification Number 3099 issued on February 11, 1997. This WQC is rescinded
when the Corps of Engineers re-authorizes these Regional General Permits or when
deemed appropriate by the Director of the DIAIQ.
The State of North Carolina certifies that the specified category of activity will
not violate applicable portions of Sections 301, 302, 303, 306 and 307 of the Public Laws
92-500 and 95-217 if conducted in dccordanee with the conditions hereinafter set forth.
Conditions of Certification:
Activities Which requue approval under either of the_.e General Pcrnut.s but
do not result in fill, dredging or excavation of waters or wetlands (such as
docks, piers or boathouses) do not require written concurrence from the
Division of Water, Quality as long as they comply with all other conditions of
this General Certiffication. However, Condition No. 5 is applicable to all
streams in basins l.vith riparian area protection rules.
In accordance with North Carolina General Statute Section 143-215.31D(e),
any request for ?I ritten concun-ence for a 401 eater Quality Certification
must include thet appropriate fee. If a project also require; a CAMA Pei-rut,
one payment to both agencies shall be submitted and will he the higher of the
two fees. The tee shall be collected and distributed betwcen [hc two agencies
in accordance with agreements reached between the Division of Water
(741a11tN' and the Division of Coastal Management,
Activitw:, vdiic:h result in fill, dredning or e.xcavation of v.atcrs or v:ctlands
unclcr thls (-jcncral Ccrtiricauuu rcyuII iIt tcn cc,W_urrcncc trvm Uic DI,, )a)vn
Oi W"aterQuallty'
Measures shall be taken to prevent live or fresh concrete from
contact \,ith ??-atCrs of the state until the concrete has hardened,
URTFR UUHL1iY h•LKiV1M ro •?.. _ .. +
Impacts to any stream length in the Neuse and Tar-Pamlico River Basins
requires written concurrence from DWQ in accordance with 15A NCAC
2B.0233 and 15A NCAC 2B.0259. New development activities located in
the protected 50-foo; wide riparian areas (whether jurisdictional wetlands or
not) within the 1\euse and Tar-Pamlico River Basins shall be limited to "uses"
identified within and constructed in accordance with 15A NCAC 2B .0233
and 15A NCAC 2B .0259. 'All new development shall be located, designed,
constructed, and. maintained to have minimal disturbance to protect water
quality to the maximum extent practicable through the use of best
management practices;
6. That appropriate sediment and erosion control practices which equal or exceed
those outlined itj the most recent version of the "North Carolina Sediment and
Erosion Control (Planning and Design -Manual" or the "North Carolina Surface
Mining Manual" k,hichevcr is more appropriate (available from the Division
of Land Resources (DLR) in the DENR Regional or Central Offices) shall be
in full compliance with all specifications governing the proper design,
installation and operation and maintenance of such Best Management
Practices in order to assure compliance with the appropriate turbidity water
quality standard;
7. Rip-rap shall belinstalled adjacent to bulkheads in freshwater lakes to ensure
protection of agijimic habitat. Construction over wetlands shall be clcvated at
least three feet above any wetlands, and floating structures shall riot rest
pcnodically on the bottom.
8. All sediment art erosion control measures placed in wetlands or kvaters shall
be removed and Ic natural grade restored after the Division of Land
ResourceS has r t ttielea.>ed the project;
9. If an environmental document is required, this Certification is not valid until a
I tndine of No Slgnficant Impact (FONSi) or Record of Dc:ci?ion (ROD) is
issued b)' tttc State Clearinghouse. All stitttcr quslit}' related conditions of th
FONSi or ROD !;(tall become conditions of this (ertifrcation:
10. Piers and boat houses shall be constructed to provide for storac,I-- and teinoval
of scNvacc rather, than allowinr rasa \va;le or other scss ale (o be disposed
din:ctlV into surf:,cc v:a(crs:
1 1 Addin rn,il site pcciftc conditions nta}' be added to projects }>ic'{? ?`-rd ith
fill Undrt this Ccr7ificztiun in of, r to errture compliance .1111 ill Ilyllc::blc
WATER QUALITY PtArtrING Fax 919-?15-56x7 May' 15' 101'i''"`1006''r`zpgpq/Qq-
12. Concurrence from DWQ that this Certification applies to an individual project
shall expire three years from the date of the cover letter from DWQ or on the
same day as the expiration date of, the corresponding Regional Permit
198200030 or 193200079, whichever is sooner,
13. Whcn written concurrence is required, the applicant is required to use the
enclosed certification of Completion form to notify DWQ when all work
included in the 401 Certification has been completed.
Non-compliance with or violation of the conditions herein set forth by a specific
fill project shall result in revocation of this Certification for the project and may result in
criminal and/or civil penalties.
The Director of the North Carolina Division of Water Quality may require
submission of a formal application for irtdivi.dual certification for any project in this
category of activity, if it is determined that the project is likely to have a significant
adverse effect upon water quality or degrade the waters so that existing uses of the
Nvetland or downstream waters are precluded.
Public hearings may be held for specific applications or group of applications
prior to a Certification decision if deemed in the public's best interest by the Director of
the North Carolina Division of Water Quality.
Effective date: 1. June 2000
DIVISION 013 WATER QUALITY
B N,
Kcrr T- Stevens
Director
wQC it 3250
US Army Cotes Of Engineers Field Offices and County Coverage
Asheville Regulatory Field Office Alexander Cherokee lredell Mitchell Union
US Army Corps of Engineers Avery Clay Jackson Polk Watauga
151 Patton Avenue Buncombe Cleveland Lincoln Rowan Yancey
Room 208 Burke Gaston Macon Rutherford
Asheville, NC 28801-5006 Cabamrs Graham Madison Stanley
Telephone: [phone] Caldwell Haywood McDowell Swain
Fax: [phone] Catawba Henderson Mecklenburg Transylvania
Raleigh Regulatory Field Office Alamance Dudaam Johnston Rockingham Wilson
US Army Corps Of Engineers Alleghany Edgecombe Lee Stokes Yadkin
6508 Falls of the Neese Road Ashe Franklin Nash Surry
Suite 120 Caswell Forsyth Northampton Vance
Raleigh, NC 27615 Chatham Granville Orange Wake
Telephone: [phone] Davidson Guilford Person Warren
Fax: [phone] Davie Halifax Randolph Wilkes
Washington Regulatory Field Office Beaufort Currituck Jones Pitt
US Anny Corps Of Engineers Bertie Dare Lenoir Tyrrell
Post Office Box 1000 Camden Gates Martin Washington
Washington, NC 27889-1000 Carteret' Green Pamlico Wayne
Telephone [phone] Chowan Hertford Pasquortmhk
Fax: [phone] Craven Hyde Perquirrt_ans "Crnatan National Forest Only
Wilmington Regulatory Field Office Anson Duplin Onslow
US Army Corps Of Engineers Bladen Hame" Pender
Post Office Box 1890 Brunswick Hoke Richmond
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone: [phone] Columbus Moore Sampson
Fax: [phone] Cumberland New Hanover Scotland
US Fish and Wildlife Service / National Marine Fisheries Service
US Fish and Wildlife Service US Fish and Wildlife Service National Marine Fisheries Service
Raleigh Field Office Asheville Field Office Habitat Conservation Division
Post Office Box 33726 160 Zillicoa Strect Pivers Island
Raleigh, NC 27636-3726 Asheville, NC 28801 Beaufort, NC 28516
Telephone: [phone] Telephone: [phone] Telephone: [phone]
North Carolina State Age ncies
Division of Water Quality Division of Water Quality State Historic Preservation Office
401 Wetlands Unit Wetlands Restoration Program Department Of Cultural Resources
1650 Mail Service Center 1619 Mail Service Center 4617 Mail Servicc Center
Raleigh, NC 27699-1650 Raleigh, NC 27699-1619 Raleigh, NC 27699 4617
Telephone: [phone] Telephone: [phone] Telephone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
CAMA and NC Coastal Counties
Division of Coastal Management Beaufort Cltowan Hertford Pasquotank
1638 Mail Service Center Bcrtic Craves Hyde Pender
Raleigh, NC 27699-1638 Btnhswick Currituck New I-lurover Perquirnans
Telephone: [phone] Cartxien Dare O slow Tyrrell
Fax: [phone] Carteret Gates Panilico Washington
N(.WRC and N(''I'rout Counties
WL-Mrtn Picxirnont RegionC:oorducnor Alfeglrany Caldwell Watauga
1855 Idlewild Road Ache Mitchell Wilkes
Kc7hxrrzville, NC 2 7 284-9 1 80 Avery Stokes
Telephone: [phone] Huriee Berry
Mountain Region Coordinator Buncoln1w Ilmidesson Polk
20830 (inat Smoky Mtn. Expressway (:hemkce Jackson Rudinjord
Waynesville, NC 28786 Clay Macon Swam
I eleplrone: [phone] 6ralcun Madison Transylvania
Fax-(828)506-i754 Maywood Mcrhowell Yancey
The following is an abbreviated application form for those applying for a 401 Water
Quality Certification to impact FERC (Federal Energy Regulatory Commission)
regulated lake shore or bottom under the U.S. Army Corps of Engineers Permit
GP30. This Application cannot be used for wetland or stream impacts. Please
provide seven (7) copies of this application and supporting information as well as a
non-refundable application fee to the Division of Water Quality of $200.00 for
impacts of to lake bottom of less than 1 acre and $475.00 for impacts to lake bottom
of greater or equal to 1 acre.
Applications should be sent to:
Division of Water Quality Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
1. Applicant Information
2
Owner/Applicant Information
Name: #e. l e n 4 ha In in, e. F-
Agent Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
it. Project Information
Fax Number:
Attach a vicinity map clearly showing the location of the property with respect to
local landmarks suclr as towns, rivers, and roads. Also provide a detailed site
plan showing property boundaries and development plans in relation to
surrounding properties. You may use the diagram below to make a hand sketch of
Telephone Number: 5,1 7 7 Za Fax Number:
E-mail Address: &%g
your project. Also, see the example below for guidance. Both the vicinity map and
site plan must include a scale and north arrow. The footprints of all buildings,
impervious surfaces, or other facilities must be included.
Location
County: A I x Z n Nearest Town: -, /D VS ? s I l
Subdivision name or site address (include phase/lot number):
Directions to site please include road numbers, landmarks, etc. (This is not
necessary if an adequate vicinity map is included):
-Sc'?nT L_c7nJ %??nhr t? LET 2? 3 G-???? l>rrc'h'c?y
he -J
2. Describe the existing land use or condition of the site at the time of this
application: $' ri r f e_
3. Property size (acres):
/It V, 5-3 had t're iLT ISI. I f? ?'az?c r
4. Nearest body ofwater (stream/river/sound/o(
r6 rzr
n/lake): 1 /{t KG ?y
5. Describe the ppurpose of the proposed work: T C-) i ?tV9i c ( 2 r
-; A:) 0 r
6. List the type of equipment to be used to construct the project: 17 A6 iv- FVVI;) L
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) below the normal pool lake level in square feetRr acres:?-IR l P deP
t ' L 0 t.() P?Lt b_ J )V fV O U ? LW&
a. Amount of impact (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) above the normal pool lake Izvel and 50 feet land Xvasquare fe
et or acres: 4k 5 ? 0l/t ? (-L 1 '"?O ?? tt b. Please describe vegetation above the normal pool lake level and 50 feet land-
ward to be impacted (numbf trees for instance): S ?r?. l" 5in?k?
I l; ?J L_ ?1n? L r (?yfi 5 `f 0 ''f i L7N
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant 1 s provided.)
C
Please approximately sketch the following information on this plan
(please provide dimensions for each Item, such as 10 ft x 100 ft):
1) All proposed vegetation clearing (provide dimensions).
.2) Location of rip rap or fill to be placed above the FtA Pond elevation
3) Location of rip rap or fill to be placed below the Fug Pond elevation
4) The location of any proposed structures such as buildings, retaining
wails, docks, etc.
5) The location of any excavation or dredging below the Full Pond
elevation.
6) Location of construction access corridors.
LJ'?G
? (?1 s S
, below full
pond i ft X IN ft
ulpeve full
pond
Please approximately sketch the fopowing information on this plan
(please provide dimnsions for each Item, such as 10 ft. x 100 ft):
1) All proposed vegetation clearing (provide dimensions)
.2) Location of rip rap or fill to be placed above the Full Pond elevation
3) Location of rip rap or fill to be placed glow the Full Pond elevation
4) The location of any proposed structures such as buildings, retaining
walls, docks, etc.
5) The location of any excavation or dredging below the Full Pond
elevation.
6) Location of construction access corridors.
0? WA T?9 Michael F. Easley, Governor
O? QG William G. Ross Jr., Secretary
y North Carolina Department of Environment and Natural Resources
j r Alan W. Klimek, P. E. Director
Division of Water Quality
p ,c / 1 1 T7- J
Coleen H. Sullins, Deputy Director
Division of Water Quality
June 29, 2004
DWQ Project # 04-0981
Alexander County
Page 1 of 2
CERTIFIED MAIL: RETURN RECEIPT REQUESTED
Helen S. Hammer
1127 Alspaugh Dam Road
Taylorsville, NC 28681
Subject Property: Crescent Land & Timber Subdivision, Lot# 263
Lake Hickory
REQUEST FOR MORE INFORMATION
Dear Ms. Hammer:
On June 17, 2004, the Division of Water Quality (DWQ) received your application dated April
14, 2004 to impact and waters to install rip rap on Lake Hickory. The DWQ has determined that
your application was incomplete and/or provided inaccurate information as discussed below.
The DWQ will require additional information in order to process your application to impact
protected wetlands and/or streams on the subject property. Therefore, unless we receive the
additional information requested below, we will have to move toward denial of your application
as required by 15A NCAC 211.0506 and will place this project on hold as incomplete until we
receive this additional information. Please provide the following information so that we may
continue to review your project.
Additional Information Requested:
1. Location Map
Please provide a location map.
Please respond within three weeks of the date of this letter by sending this information to me in
writing and Alan Johnson of the DWQ Mooresville Regional Office. If we do not hear from you
within three weeks, we will assume that you no longer want to pursue this project and we will
consider the project as withdrawn.
N. C. Division of Water Quality, 401 Wetlands Certification Unit,
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
[phone] (phone), 919-733-6893 (fax), (http://h2o.enr.state.nc.us/ncwetlands)
Customer Service #: 1-877-623-6748

Helen S. Hammer
Page 2 of 2
June 29, 2004
This letter only addresses the application review and does not authorize any impacts to wetlands,
waters or protected buffers. Please be aware that any impacts requested within your application
are not authorized (at this time) by the DWQ. Please call Ms. Cyndi Karoly or Mr. John Dorney
at 919-733-1786 if you have any questions regarding or would like to set up a meeting to discuss
this matter.
Sincerely,
LC L
Dorney,
?, Wetlands / 40 nit
JRD/bs
cc: Alan Johnson, DWQ Mooresville Regional Office
USACE Asheville Regulatory Field Office
File Copy
Central Files
Filename: 04.0981 Helen Hammer (Alexander) On Hold
oW AT F9p?
v? r
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P. E. Director
Division of Water Quality
Coleen H. Sullins, Deputy Director
Division of Water Quality
May 17, 2004
CERTIFIED MAIL
Helen S. Hammer
1127 Alspaugh Dam Road
Taylorsville, NC 28681
Dear Ms. Hammer
() 4?'g 81
On 5/17/04, the Division of Water Quality received your application for a General 401 Permit
certification in Alexander County, North Carolina. Please note that beginning January 1, 1999,
the N.C. General Assembly passed legislation requiring payment of a fee for all 401 applications.
This fee requirement is stated on your Application Form. Your application is being returned
since no payment was received with the package. The fee for applications is $200 for projects
impacting less than an acre of wetland and less than 150 linear feet of streams. For projects
impacting one or more acres of wetland or 150 or more feet of streams, the fee is $475. In order
for DWQ to begin review and process your request, you must send a check in the appropriate
amount made payable to the N.C. Division of Water Quality attached to your application.
If you have any questions regarding this letter please do not hesitate to call me at (919)-733-
1786.
Sincerely,
Enclosed: 401 Application Packets received 5/17/04
CC: Central Files
y? WETLANDS/401 GROUP
tc j' ro- JUN 1 2004
4??
WATER QUALITY SEC Tlott

N. C. Division of Water Quality: Wetlands/401 Unit 1650 Mail Service Center Raleigh, North Carolina 27699 [phone]
0? FIB
L 960VU
I Lf
106� A�
Al
A Y
('00

DWQ# _ ?/ I Date Who Reviewed;
Plan Detail Incomplete
C4 Please provide a location map for the project.
? Please show all stream impacts including all fill slopes, dissipaters, and bank stabilization on the site plan. `
? Please show all wetland impacts including fill slopes on the site plan.
? Please indicate all buffer impacts on the site plan.
? Please indicate proposed lot layout as overlays on the site plan.
? Please indicate the location of the protected buffers as overlays on the site plan.
? Please locate all isolated or non-isolated wetlands, streams and other waters of the State as overlays on the site plan.
? Please provide cross section details showing the provisions for aquatic life passage. -- -.- -•• -- -• - --
? Please locate any planned sewer lines on the site plan.
? Please provide the location of any proposed stormwater management practices as required by GC
? Please provide detail for the stormwater management practices as required by GC
? Please specify the percent of project imperviousness area based on the estimated built-out conditions.
? Please indicate all stormwater outfalls on the site plan.
? Please indicate the diffuse flow provision measures on the site plan.
? Please indicate whether or not the proposed impacts already been conducted.
Avoidance and/or Minimization Not Provided
? The labeled as on the plans does not appear to be necessary. Please eliminate the or provide additiobal
information as to why it is necessary for this project.
a
? This Office believes that the labeled on the plans as can be moved or reconfigured to avoid the impacts to the
Please revise the plans to avoid the impacts.
? This Office believes that the labeled on the plans as can be moved or reconfigured to minimize the impacts to the
Please revise the plans to minimize the impacts. F
? The stormwater discharges at the location on the plans labeled will not provide diffuse flow through the buffer because 7
Please revise the plans and provide calculations to show that diffuse flow will be achieved through the entire buffer. If it
is not possible to achieve diffuse flow through the entire buffer then it may be necessary to provide stormwater management
practices that remove nutrients before the stormwater can be discharged through the buffer.
Other
? The application fee was insufficient because over 150 feet of stream and/or over 1 acre of wetland impacts were requested. Please
provide $ . This additional fee must be received before your application can be reviewed. !
? Please complete Section(s) on the application.
? Please provide a signed copy of the application.
? Please provide copies of the application, copies of the site plans and other supporting information.
Mitigation
? of compensatory mitigation is required for this project. Please provide a compensatory mitigation plan. The
plan must conform to the requirements in 15 A NCAC 2H.0500 and must be appropriate to the type of impacts proposed.
? Please indicate which 404 Permit the USACE would use to authorize this project.
CORY ?J -
UNITED STATES POSTAL SERV -> First-Class Mai( --
Postage & Fees Paid
LISPS : '..
Permit No. G-10 ` `
• Sender: Please print your name, address, and ZIP+4 in this box •
NC DENR Division of Water Quality
Wetlands/401 Certification Unit
2321 Crabtree Boulevard, Suite 250
Raleigh, NC 27604
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.
Article Addressed to:
Helen S. Hammer
1127 Alspaugh Dam Road
Taylorsville, NC 28681
DWQ# 04-0981 - Alexander
A. Signature
- ? Agent
X
Ad esse
461?
10
B. Received by (Printed Name) C. Date of Deliver
'I P zl Y
D. Is delivery qi ferent from item l? ? Yes
If YES„ every below: ? No
a Y
TO
3. Service Type - ,,?,
Certified Mail ,.ttkpress Mail
? Registered PQ Return Receipt for Merchandis
? Insured Mail ? C.O.D.
? Yes
2. Article Number - a 1 1
fTransrerfrom servic 7001 2510 0009 0250 7465
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