Homesite Lease Application Page 5
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6FIELD CLEARANCE CERTIFICATION
FOR
HOMESITE LEASE APPLICATION
I, __________________________________________________, Grazing Official or Land Board Member of Grazing Management
District_________,
community
of
_____________________________________________________________Chapter
have
identified the following individuals as land use or grazing permittee(s) who are directly affected by the proposed homesite
development as illustrated and proposed by the following homesite lease applicant(s):
______________________________________________
______________________________________________
Homesite Lease Applicant
Homesite Lease Applicant
(Print Name)
(Print Name)
AUTHORIZED GRAZING /LAND USE PERMITTEE
(THIS IS NOT A CONSENT FORM)
NAME
CENSUS NO.
PERMIT NO.
1.
__________________________________________
_______________
________________________
2.
__________________________________________
_______________
________________________
3.
__________________________________________
_______________
________________________
4.
__________________________________________
_______________
________________________
5.
__________________________________________
_______________
________________________
CERTIFICATION
According to my records and to the best of my knowledge, the list of the affected permittee(s) referenced above includes all of
the permitted land users who are directly affected by the proposed homesite development.
1.
Are there any improvement(s) on the proposed site? (i.e. Roads, Trails, Power lines, etc.) If so, describe:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2.
Is there a permanent structure on the proposed site? ________________ If so, when was the house built? ________________
Does the applicant now live in the house? _________________
______________________________________________________
___________________
Grazing Official/ Land Board Member
Date
FORM – FCC06
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