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I, LXG 1L , hereby authorize 'T 4"f Lcr_5(r2 <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 /> (project name) <br /> • <br /> S. . re of•wner Date <br /> Name printed <br /> STATE OF WISCONSIN, County of Dane <br /> Subscribed and sworn to before me on <br /> by the above named person. (date) <br /> Signature of Notary <br /> Print or type name <br /> Date commission expires <br /> Seal: <br />