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i, 7:9-Ncta EU6-11 r. , hereby authorize J - /4/ e, <br /> (landowner) t) <br /> (applicant) <br /> to act as my agent for the purpose of submitting an erosion control and/or stormwater <br /> management application to the Dane County Land &Water Resources Department for <br /> gU dlivef i • p li / ,rivf 6t,e._, <br /> (project name) <br /> l��Ge - 771 i .A-- X3- 15 <br /> ( A____7- / Cs / l n--- <br /> Signature of Owner Date <br /> c c cam. NA- N. cz- <br /> 1 b.tk 1 . 'c c_\,\:,,.es— <br /> Name printed <br /> I <br /> STATE OF WISCONSIN,County of Dane <br /> Subscribed and sworn to before me on 7/ 3//5-- <br /> by the above named person. (date) <br /> Signature of Notary A _4 <br /> Print or type name c�L+c.�:'Pkc.. t Jc A S <br /> Date commission expires 1/2S.72.619 <br /> Seal: <br /> GQUEL/Nc,•• <br /> i <br /> P••N. \�••_ <br /> 7.-/q RY �u) <br /> 7, A'&Lrc <br /> • OF w ISCONS•' <br /> I <br /> 1 <br />