NCC232369_FRO Submitted_20230808

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
i Dot be an
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N(1RIH CAROL!NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Norwood Park Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street Mt Vernon Church Rd Latitude 35.943286 Longitude -78.671846
3. Approximate date land-disturbing activity will commence: August 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.37 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Mangum E-mail Address [e-mail]
Telephone [phone] Cell# 919-422-2126 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
NGI Investments LLC
Name(s) Telephone Fax or E-mail address
PO BOX 91327 Raleigh NC, 27675 0 Norwood Road
Current Mailing Address Current Street Address
Raleigh N.C. 27614
City State Zip City State Zip
8. Deed Book No.18883 Page No. 764 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Mangum Design Build [e-mail]
Name E-mail Address
6701 Mt. Herman Rd.
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially 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 Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 the 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
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Kevin gum / ''NAffit-
Type print name Title or Authority
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Si re Date
I, S\-e-.@\n .\\ , a Notary Public of the County of \NN,0.‘L9—
State of North Carolina, hereby certify that �Q,�:��� � `N� appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 1 day of Vc� V , 20
Notary
Seal
My commission expires Qom.\ �a�a
S PHANIE 5 HARRIS
Notary,��Public
MMWaky County,
m�misslion Edna
AO 08,2026