Form 4120-7
May 2020)
OMB NO. 1004-0019
Expires: March 31, 2023
State Code ........................
Ofce Code .....................
Authorization Number ....
Allotment Number ..........
Project Number ...............
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 Ofce
for approval. Upon approval, BLM returns the original to the applicant, and les one copy in the
applicant’s grazing case record and one copy in the BLM project record.
Date Filed
Name (last, rst, 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:
If this permit is for a new project, specications for this improvement must accompany this application.
The improvement is to be located in Section , Township , Range , Meridian,
County of , State of . The location is shown on the diagram on page 2 hereof.
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 DateSignature of Applicant
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,
ctitious, or fraudulent statements or representations as to any matter within its jurisdiction.
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 shing
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 specications attached
and any special conditions made a part of the permit. Special conditions
and/or specications 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
(Month) (Day) (Year)
Date Approved
Approved by BLM (printed name, signature, and title)
(Continued on page 2) (Form 4120-7)
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Sec. , T. , R. Mer.
For unsurveyed lands, attach U.S.G.S. quadrangles or sketch maps
to show improvement location.
Scale inches equals one mile
This improvement has been completed satisfactorily on , 20 , at a cost of
$ for materials and $ for labor, in accordance with conditions of the permit.
Date of Inspection Printed Name of Inspecting Ofcer Signature of Inspecting Ofcer
(Continued on page 3) (Form 4120-7, page 2)
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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 benet.
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 benet.
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 Ofcer (WO-630), 1849 C Street, N.W., Washington, D.C. 20240.
(Form 4120-7, page 3)