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 on more than one-half acre as covered by the
Act before this form and an acceptable erosion and sedimentation control/stormwater plan have been completed and
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 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
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: ________________________________________ PIN _______________________
2. Location of land-disturbing activity/stormwater installation: (City or Township) __________________
Highway/Street _____________________ Latitude _______________ Longitude_______________
3. This project will require the review of the following: Erosion Control Stormwater
Is this project within a regulated district? No Yes District: _____________________________
4. Approximate date work will begin onsite:________________________________________________
5. Purpose of development (residential, commercial, industrial, etc.) _______________________________
6. Total acreage disturbed or uncovered (including off-site borrow and waste areas)__________________
7. Amount of fee $______________ FOR OFFICE USE: Received? (initial/date) ________________________
8. Has an erosion & sedimentation control/stormwater plan been filed? No Yes Enclosed
9. Person to contact should issues arise during land-disturbing activity/stormwater installation:
Name ______________________________ E-mail Address _______________________________
Phone _____________________ Cell _____________________ Fax _____________________
10. Landowners(s) of Record
(Use blank page to list additional owners) Deed Bk/Pg _____________ (Provide a copy)
Name ______________________________ Phone _________________ Fax _________________
Current Mailing Address_____________________________________________________________
Part B
Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship, the name of the
owner or manager may be listed as the financially responsible party.
_______________________________________ _______________________________________
Name E-mail Address
_______________________________________ _______________________________________
Mailing Address Street Address
_______________________________________ _______________________________________
City State Zip Code City State Zip Code
_______________________________________ _______________________________________
Phone Fax Number
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.
_______________________________________ _______________________________________
Name E-mail Address
____________________________________ _______________________________________
Mailing Address Street Address
____________________________________ _______________________________________
City State Zip Code City State Zip Code
____________________________________ _______________________________________
Phone Fax 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 E-mail Address
____________________________________ _______________________________________
Mailing Address Street Address
_______________________________________ _______________________________________
City State Zip Code City 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 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.
my hand and notarial seal, this _____ day of _________________________, 20_____.
My Commission Expires ________________________________
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 Unified Development Ordinance (Section 5.3.11), 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 5.3.11 (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 5.3.11 (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 __________________