Form 4120-7 Range Improvement Permit

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Form 4120-7
(May 2014)

FORM APPROVED
OMB NO. 1004-0019
Expires: October 31, 2016
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

,

Meridian,

. The location is shown on the diagram on page 2 hereof.
, for materials which will be paid for or furnished by the applicant.

, for labor and/or; $

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. 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 BLM (printed name, signature, and title)

(Continued on page 2)

conditions and/or specifications attached:

Yes

No

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)

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 and 43 CFR 2.48(d) require that you be furnished with the following information in connection with the information

requested by this form.

AUTHORITY: 43 U.S.C. 315, 43 U.S.C. 1752, 43 U.S.C. 1181d, and 43 CFR subpart 4120 permit collection of the information requested
by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to develop a permit for the construction, use, and maintenance
of range improvements on its public lands .

ROUTINE USES: The BLM will only disclose this information in accordance with the Freedom of Information Act, the Privacy Act,
the Debt Collection Improvement Act, and the provisions at 43 CFR 2.56(b) and (c), consistent with the System of Records Notice in
effect at the time of completing this application.

EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to obtain or retain a benefit.
Failure to submit all of the requested information or to complete this form may result in delay or the rejection and/or denial of your
application.

The Paperwork Reduction Act requires that you be furnished with the following information in connection with the information
requested by this form :

The BLM collects this information in accordance with the statutes and regulations listed above, and for the purposes listed above.
Submission of the requested information is necessary to obtain or retain a benefit.

You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a valid
OMB control number.

BURDEN HOURS STATEMENT: The 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. You may submit 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., Washington, D.C. 20240.

(Form 4120-7, page 3)