Nonmetallic Mineral Deposit - Registration Form

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Registration of Marketable
Document Number
Nonmetallic Mineral Deposit
Type or print in black ink, keeping inside lined margins
1. By this instrument the following landowner(s):
2. Who own(s) land located in _______________ county,
SPACE RESERVED FOR RECORDING INFORMATION
Wisconsin and with a current legal description of the land to be
registered as set forth below (attach additional materials if
NAME AND RETURN ADDRESS
necessary):
___________________________
PARCEL IDENTIFICATION NUMBER [PIN]
3. Do hereby claim the land contains a marketable nonmetallic mineral deposit as defined in s. NR 135.54,
Wis. Adm. Code based on the following certification and delineation by a Wisconsin registered professional
geologist or registered professional engineer, in conformance with s. NR 135.56(1), Wis. Adm. Code (attach
additional information or materials as necessary):
4. Attestation to the information in 3. above by the Wisconsin registered professional geologist or
registered professional engineer:
I hereby certify that this document contains a description of a marketable nonmetallic mineral
deposit consistent with the requirements of Chapter NR 135, Wisconsin Administrative Code.
Name, Title
________________________________________________________
Signature
________________________________________________________
SEAL:

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