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Dane County Water Resource Engineering <br /> Permit Applicant Authorization Form <br /> (24 /lac r / L l° hereby Z , hereb authorize - i/( >� to act <br /> lamlowner printed name applicant printed name <br /> as my agent for the purpose of applying for and obtaining erosion control and/or stormwater <br /> management permit(s) from Dane County Land &Water Resources Department for <br /> 1„is 2 kz; ro I t”4 /lot U 't�`? ) AslandownerH <br /> project printed ovine � <br /> understand I am bound by the requirements of the county erosion control and stormwater <br /> mamas,- -nt ordinance and am responsible for implementation of the plan. <br /> II(ia <br /> of owner Date <br /> cA <br /> L- (Abri c 4fc-_- <br /> Pm1ea Name <br /> State of Wisconsin,County of Dane <br /> This instrument was signed or attested before me on <br /> by the above named person. <br /> Signature of Notary <br /> Printed Name `- <br /> My Commission expires. <br /> seat <br /> revised 8.22,017 <br /> 1 <br />