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JACKSON COUNTY PERMITTING & CODE ENFORCEMENT

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____.

____________________________________________________

Notary

Seal

My Commission Expires ________________________________

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JACKSON COUNTY PERMITTING & CODE ENFORCEMENT

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 __________________

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