Form 4120-7 Range Improvement Permit

UNITED STATES
DEPARTMENT OF THE INTERIOR

Form 4120-7
(April 2004)

FORM APPROVED
OMB NO. 1004-0019

Expires: March 31, 2007

BUREAU OF LAND MANAGEMENT
APPLICATION AND APPROVAL FOR

FOR BLM USE ONLY

RANGE IMPROVEMENT PERMIT

State Code.

...............

..............
Authorization Number. . . . . . . .

FOR REMOVABLE AND/OR TEMPORARY IMPROVEMENTS

Office Code.

INSTRUCTIONS - Type or print plainly in ink. Applicant completes
application through applicant signature and date. Applicant then
submits it to the appropriate Bureau of Land Management (BLM) Field Allotment Number . . . . . . . . . .
Office for approval. Upon approval, BLM returns the original to the
applicant and files one copy in the applicant’s grazing case record and Project Number. . . . . . . . . . . . .
one copy in the BLM project record. Signatures must be handwritten Date Filed
in ink.
Name (last, first, middle initial)

Mailing Address (include zip code)

Applies for a permit to
construct, maintain, and use
maintain and use in connection with the applicant’s grazing permit or lease, and subject to
the permit conditions set forth below, the following described removable and/or temporary improvement on public lands:
The purpose, need, and use for such improvement is as follows:

,Township

The improvement is to be located in Section
County of

, State of

,

, Range

,

Meridian,

The location is shown on the diagram on the reverse hereof. Specifications for the

improvement accompany this application.
Estimated cost of improvement is: $

, for labor and/or; $

, for materials which will be paid for or furnished by the applicant.

Estimated present value of the improvement is $
Signature of Applicant

Signature Date

Title 18, U.S.C., Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any
false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
FOR BLM USE ONLY

PERMIT CONDlTlONS AND APPROVAL
A permit is hereby issued subject to the following conditions:
1. The permit shall cover only such portions of temporary or removable
range improvements and livestock handling facilities as are actually
located upon public lands. Examples of removable or temporary
facilities and improvements are: corrals, creep feeders, loading chutes
and portable storage tanks and troughs for hauled water.
2. The permit does not convey right, title, or interest in any lands or
resources held by the United States.

3. The permit is subject to cancellation in whole or in part if the lands or
portions thereof are disposed of or devoted to a public purpose which
precludes livestock grazing.
4. The permittee will be responsible for properly maintaining the
improvement in good working order and in an aesthetic state. The
permittee will comply with laws of the State within which the
improvements are listed.

5. Any public lands or livestock waters will be available for wildlife use,
wild horses and burros, and open to the public for hunting and fishing
in accordance with State regulations. Such lands and water will also
be open for other authorized public use to the extent that such use is
consistent with the multiple-use management objectives for the area.
6. The permittee must comply with the construction specifications
attached and any special conditions made a part of the permit. Special
Approved by Bureau of Land Management (printed name, signature, and title)
(Continued on page 2)

conditions and/or specifications attached:

Yes

No

7. The permit is subject to modification or cancellation if the
improvement no longer serves the purpose for which it was installed or
if the improvement is not compatible with the multiple-use objectives
for the area. The permit is subject to cancellation if the permittee does
not comply with the regulations under which the improvement is
authorized (43 CFR Parts 4100).
8. Within thirty (30) days after completion of the improvement, the
permittee must advise the Bureau of Land Management in writing: (a)
the date the job was completed; and (b) total cost of the job,
specifying separately the cost of labor and materials.
9. This permit is subject to the provisions of Executive Order No. 11246
of September 24, 1965, as amended, which set forth the
nondiscrimination clauses. A copy of this order may be obtained from
the Bureau of Land Management.
10. If the permit is for construction of any improvement, it shall become
void without further notice if it is not constructed by:

(Month)

(Day)
Date Approved

(Year)

LOCATION PLAT
,T.

,R.

,

Mer.

On unsurveyed lands, U.S.G.S. quadranges, sketch maps, etc,
as attachment to show improvement location

Sec.

Scale:

inches equals one mile

TO BE FILLED IN UPON COMPLETION OF IMPROVEMENT
This improvement has been completed satisfactorily on
$
Date of inspection

for materials and $

, 20

, at a cost of

for labor, in accordance with conditions of the permit.

Signature of Inspecting Officer

PRIVACY AND PAPERWORK REDUCTION ACT STATEMENT
The Privacy Act of 1974 and the Paperwork Reduction Act of 1995 provide that you be furnished the following information in connection with information required by this
permit.
AUTHORITY: 43 U.S.C. 315, 316, and 1181d.
PRINCIPAL PURPOSE: The information is to be used to process this application.
ROUTINE USES: (1) The determination of the applicant’s requirements and need to construct or maintain improvements on public lands. ( 2 ) Information will be used to
authorize the construction, maintenance , and use of range improvements. (3) Documentation for public information in support of notations made on land status records for
the management, disposal, and use of public lands and resources. (4) Transfer to appropriate Federal agencies when concurrence is required prior to granting a right in public
lands or resources. (5)(6) Information from the record and/or the record will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil,
criminal or regulatory investigations or prosecutions. Response to this request is voluntary.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is required to obtain a benefit in accordance with Sections 4 and 15 of the Taylor Grazing
Act, Section 11 of the Alaska Grazing Act, and Section 302 of the Federal Land Policy and Management Act.
Unless this form contains a currently valid OMB Control Number, you are not required to submit this information to the BLM or its designated agents.
Public reporting burden for this form is estimated to average 20 minutes per response, including the time for reviewing instructions, gathering and maintaining data and
completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land
Management (1004-0019), Information Collection Clearance Officer, (WO-630) 1849 C Street, N.W., Washington, D.C. 20240
(Form 4120-7, page 2)