Form 4120-7 Range Improvement Permit

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Form 4120-7
(July 2007)

FORM APPROVED
OMB NO. 1004-0019
Expires: May 31, 2010
FOR BLM USE ONLY

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
APPLICATION AND APPROVAL FOR

State Code……………….. ________________

RANGE IMPROVEMENT PERMIT

Office Code……………… ________________

FOR REMOVABLE AND/OR TEMPORARY IMPROVEMENTS
INSTRUCTIONS - Type or print plainly in ink. Applicant completes form through "Signature of
Applicant" and "Signature Date." Signatures must be handwritten in ink. Applicant then submits
permit application to the appropriate Bureau of Land Management (BLM) Field Office for approval.
Upon approval, BLM returns the original to the applicant, and files one copy in the applicant's
grazing case record and one copy in the BLM project record.
Name (last, first, middle initial)

Reset

Authorization Number....... ________________
Allotment Number………. ________________
Project Number………….. ________________
Date Filed

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:

If this permit is for a new project, specifications for this improvement must accompany this application.
The improvement is to be located in Section
County of

, Township

, State of

Estimated cost of improvement is: $

, Range

,

Meridan,

. The location is shown on the diagram on the reverse hereof.
, 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 will 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 must maintain 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.

6.

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.

conditions and/or specifications attached:

Yes

7. BLM may modify or cancel this permit 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. BLM may cancel
this permit if the permittee does not comply with the regulations under
which the improvement is authorized (43 CFR Part 4100).
8.

Within thirty (30) days after completion of the improvement, the permittee
must advise the BLM 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 BLM.

10. If the permit is for construction of any improvement, it will become void
without further notice if the improvement is not constructed by:

_____________________
(Month)

_____________ _______________
(Day)
(Year)

The permittee must comply with the construction specifications attached
and any special conditions made a part of the permit. Special

Approved by BLM (printed name, signature, and title)

(Continued on page 2)

No

Date Approved

LOCATION PLAT
, T.

, R.

,

Mer.

For unsurveyed lands, attach U.S.G.S. quadrangles or sketch maps
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

(Continued on page 3)

for materials and $
Printed Name of Inspecting Officer

, 20

, at a cost of

for labor, in accordance with conditions of the permit.
Signature of Inspecting Officer

(Form 4120-7, page 2)

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) 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 authorize and document construction, use, and maintenance of range
improvements.
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.
EFFECT OF NOT PROVIDING INFORMATION: If you do not file this permit and furnish the requested information, you will not be
authorized to place improvements on public lands. If the improvement is placed without proper authorization, you will be liable for
damages and immediate removal of the facility.
The Paperwork Reduction Act of 1995 requires that we inform you that:
The BLM collects this information to process your application for a Range Improvement Permit.
Response to this request is required to obtain a benefit.
The BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection
unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 2 hours 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), Bureau
Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

(Form 4120-7, page 3)