Form 4120-7
(
May 2020)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
APPLICATION AND APPROVAL FOR
RANGE IMPROVEMENT PERMIT
FOR REMOVABLE AND/OR TEMPORARY IMPROVEMENTS
FORM APPROVED
OMB NO. 1004-0019
Expires: March 31, 2023
FOR BLM USE ONLY
State Code ........................
Ofce 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 Ofce
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, specications 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.
FOR BLM USE ONLY
PERMIT CONDITIONS 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 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 specications attached
and any special conditions made a part of the permit. Special conditions
and/or specications 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
Approved by BLM (printed name, signature, and title)
(Continued on page 2) (Form 4120-7)
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