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I, � lz�� � , hereby authorize (10-4/tOk EXtetritc) <br /> (landowner) (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 /> aaa f)3LOPj Pmt O (.21...0,„,- `,- <br /> (project name) <br /> 41,24A} / / <br /> Signature of Owner Date <br /> kW. /✓ ,�,�R <br /> Name printed <br /> STATE OF WISCONSIN,County of Dane <br /> Subscribed and sworn to before me on OS U 201(Q <br /> by the above named person. (date) <br /> Signature of Notary /-4,41A,1- . <br /> Print or type name P4i 141 A_ &d <br /> Date commission expires oq-�5--°2_01ce <br /> Seal: <br /> Kaj _e/i\e/.1k6 sad <br />