NCC223860_FRO Submitted_20221117

u�gpN COGS
Z0 "'
9}�l CAVk
JACKSON COUNTY PERMITTING & CODE ENFORCEMENT
Land Disturbance: One -Half (112) or more .4eres/Stormwater Installation
Financial ResponsibiligvOwnerskip Form
Svlva Office: 538 Scotts Creek Road, Suite 205, Phone: [phone] / Fax: [phone]
Cashiers Office: 357 Frank.Allen Road, Phone: [phone]/Fax: [phone]
do perso❑ rnav initiate a land -disturbing acticim and or stomtcrarer installation on more than one-half acre as covered by the
\et before this form and an acceptable erosion and edimentarion control stormwatcr plan have been completed and
approv ed by the. Iackson County Office of Permitting & (:ode I riforccmc a If work is started without an approved permit
our pernut tcc ill he (Imuhled.
• Please type or print, and if any question is not applicable or the e-mail and/or fax information unavailable,
place N/A in the blank.
• Submit three (3) copies of the plan, A narrative, and the appropriate fee; please contact our office for an
accurate fee calculation before submitting paperwork. For fee calculation call 828-745-6850 or e-mail
tiffanyguallsfh'jacksonne.org or jamiebaumgarner(a�jacksonnc.org.
• A surety bond is required for any disturbance of five (5) acres or more
n,, A
1. Project Name: Tatham Campground Expansion PIN 7528-78-7569
2. Location of land -disturbing activity/stormvvatcr installation: ((,itv or'1,ownship) Savannah
Highvvav/Street Ralph Tatham Road I :antude 35.2941 longitude-83.2643
3. This project will require the review of the hollowing: �✓ 1:rt>sion (:ontrol R]Stormvv-ater
is this project within a regulated district-InNo D"es — District.
4. Approximate date work will begin onsitc:111/2023
5. Purpose of development (residential, commercial, industrial, etc.) aMP91011nd
6. Total acreage disturbed or uncov crcd (including off -site borrow and waste areas) 4.98
7. Amount of fee S 1750 I OR ( )I I I( r: 1 _151.: R(ccn cd= (initial date;
8. 1Ias an erosion & sedimentation control/stormwater plan been filed ONo Dyes ✓Enclosed
9. Person to contact should issues arise during land -disturbing activity/stormwater installation:
Name Jack Jawitz F.-mail :address jackjawitz(a)Mail.corn
Phone [phone] (:ell
I-ax
10. Landowncrs(s) of Record (Ose blank page to list additional owners} Deed Bk/Pg 2301/1394 (Provide a copy)
Name Aaron & Norah LLC Phone [phone] Fax
Current Mailing Address 2919 26th St W, Bradenton,FL 34205
Part B
Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
c)mprchcnsiv e list of all responsible petrties on an att,uhcd shccr.If the compam or firm is It sole proprietorship, the name of the
r,cxncr or manager mac he listed as the tinancialh resp,)nsihlc p:trt�.
Aaron & Norah LLC -
Namc
2919 26th St. W _.
Mailing :\ddress
Bradenton FL 34205
state/.ip Oc
941-650-5015
Phunc
jackjawitzL.com
1 -mail \ddrrss
2919 26th St. W
Street Address
Bradenton FL 34205
(,m ')rate Zip Code
fax Numher

1. (a) If the Financially Responsible Party is not a resident of North Carolina, please give name and street
address of a North Carolina Agent.
Diane Brazier
Name
F,-mail Address
356 Ralph Tatham Road
356 Ralph Tatham Road
Mailing Address
Street Address
Sylva 28779
Alva NC 28779
_NC
City state Zip Cade
Cite state Zip code
Phone
lax Number
(b) If the Financial Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financial Responsible
Party is a Corporation, give name and street address
of the Registered Agent.
Name of Registered Agent
I : mail Address
Mailing Address
Strcet Address
City StatC Zip Code
Ctt}' State Zip Code
Phone
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me under
oath. (This form must be signed by Financially Responsible Person if an individual or his attorney -in -
fact, or if not an individual, by an officer, director, partner, or registered agent with authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there
be any changes in the information provided herein.
Type or
Company Official
Title o Aut rit5
i ZG�z Z.
Da
a Notary Public of the County of '[� (1 J(yJC S-P-Q�
State off hereby certify that [t (� \[ate 1 �� appeared personally
V io!k -
before me this day and being duly s-,vorn acknowledged that the above form was executed by Him/Her.
Witness my hand and notarial seal, this day of 0r l i��i\— 20A�a•
S'eul
yly Commission Expires 7:� ufe_ LPA+y
C *; CASEYBRINN
MY COMMISSION #HH249
EXPIRES: Juno6,2M