ANTELOPE COUNTY CONSENT FORM

For use with conditional use permits as needed

_______________

             date

I, ________________________________________________________, do hereby consent to allow

 _________________________________________________to apply effluent through the center pivot on

land that I own or do hereby allow them to apply effluent on land that I own by use of a tank wagon or injection, legal description of land being,

______________________________________________________________________________.   This

consent form begins on _______________and ends on ___________________________.                                                                                          

                                                                       (dates if applicable)

________________________________                                     _________________________________

                               Signed by landowner                                                                  Signed by applicant

Notorized by ___________________________________________

Updated 9-18-08