Land Disturbance: One-Half (1/2) or more Acres/Stormwater Installation
Financial Responsibility/Ownership Form
Sylva Office: 401 Grindstaff Cove Rd, Suite 145, Phone: 828-586-7560 / Fax: 828-586-7563
Cashiers Office: 357 Frank Allen Road, Phone: 828-745-6850 / Fax: 828-745-6867
No person may initiate a land-disturbing activity and/or stormwater installation before this form has been
completed and an acceptable erosion and sedimentation control/stormwater plan has been approved by the
Jackson County Office of Permitting & Code Enforcement. If work is started without an approved permit
your permit fee will be doubled.
Please type or print, and if any question is not applicable 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 tiffanyqualls@jacksonnc.org or jamiebaumgarner@jacksonnc.org.
A surety bond is required for any disturbance of five (5) acres or more
Part A
1. Project Name: ______________________________________________________________
2. Parcel Identification Number (PIN)___________________________________________
3. Location of land-disturbing activity/stormwater installation: (City or Township) ______________,
Highway/Street _____________________________________________________________
4. This project will require the review of the following: Erosion Control Stormwater
5. Is this project within a regulated district? No Yes District: _______________________
6. Approximate date work will begin onsite:__________________________________________
7. Purpose of development (residential, commercial, industrial, etc.) ____________________________
8. Total acreage disturbed or uncovered (including off-site borrow and waste areas) ______________
9. Amount of fee $_____________ FOR OFFICE USE: Received? (initial/date) _____________________
10. Has an erosion & sedimentation control/stormwater plan been filed? No Yes Enclosed
11. Person to contact should issues arise during land-disturbing activity/stormwater installation:
Name __________________________________ Telephone _________________________
E-mail Address______________________________________________________________
12. Landowners(s) of Record (Use blank page to list additional owners)
Name(s) ___________________________________________________________________
Current Mailing Address__________________________________________________________________
Part B
1. Person(s) or firm(s) who are financially responsible for activity onsite:
_______________________________________ _______________________________________
Name Mailing Address
_______________________________________ _______________________________________
Telephone City State Zip Code
E-Mail Address
2. (a) If the Financially Responsible Party is not a resident of North Carolina, please give name and
street address of a North Carolina Agent.
_______________________________________ _______________________________________
Name Mailing Address
_______________________________________ _______________________________________
Telephone City State Zip Code
E-Mail Address
(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 Mailing Address
_______________________________________ _______________________________________
Telephone City State Zip Code
E-Mail Address
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 Print Name Title or Authority
___________________________________________ _________________________________________
Signature Date
I, ______________________________, a Notary Public of the County of _________________________,
State of North Carolina, hereby certify that ___________________________________ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by Him/Her.
Witness my hand and notarial seal, this _____ day of _________________________, 20____.
My Commission Expires ________________________________
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Request for Surety Bond to Disturb Land
*Only Required for Five or More Acres of Land Disturbance*
Sylva Office: 401 Grindstaff Cove Rd, Suite 145, Phone: 828-586-7560 / Fax: 828-586-7563
Cashiers Office: 357 Frank Allen Road, Phone: 828-745-6850 / Fax: 828-745-6867
Per the requirements of the Jackson County Code of Ordinances (Chapter 10, Environment, Article VI,
Jackson County Sediment Control Ordinance
, Division 5, Section 10-310), Jackson County hereby asks
for the issuance if a surety bond to be held by the County for the following project:
Project Name: _________________________________________________________________________
Property Identification Number: ___________________________________________________________
Land Owner(s) of Record: ________________________________________________________________
Financially Responsible Person: ____________________________________________________________
Project or Site Location:__________________________________________________________________
The reason for this bond request is as follows: As per Section 10-310 (3) of the ordinance, “Forfeited
surety shall be used to establish erosion control structures or ground cover in accordance with an approved
sediment control plan.”
Conditions of default for the right of redemption: As per Section 10-310 (1) of the ordinance, “Land-
disturbing activities not in compliance with this ordinance or an approved sediment control plan for 90
working days after notice of violation is received through registered mail or certified mail or other means
detailing specific items of violation, shall be subject to forfeiture of all applicable surety.
Please be advised that, as per the ordinance, “Such surety shall be valid until the land-disturbing
activity is completed in accordance with the approved sediment control plan and released by the
Administrator…” As a matter of standard operating procedure in Jackson County’s Erosion Control
Program, it has been determined by the Commissioners that the land-disturbing permit for any site required
to have a surety bond will only be in effect for the same amount of time that the bond is in force. If the
bond lapses before the County closes out the site, the land-disturbing permit will be revoked immediately.
If the bond applicant (which will likely be the person financially responsible for the project or the land owner
of record) allows the bond to prematurely expire (before the permitted area is closed out by the County),
applicable violations on the area being disturbed will be cited and a new application for a permit to disturb
land will be called for by the County. Please be advised this means civil penalties may be assessed, and all
application fees will again have to be paid at current applicable rates.
An application to disturb ________________acres of land in Jackson County has been
submitted by ______________________________________. At the rate of $ ___________
per acre disturbed, the total surety bond amount requested will now be stated as
$ ___________. The original bond will be held by “Jackson County”, and should be sent to
the above stated address.
By: ___________________________________ for Jackson County on __________________