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Instructions for Completion of Application for Sanitation Facilities

This instruction is to aid the individual Applicant requesting sanitation facilities and accompanies the Application for Sanitation Facilities Form (DOC 36KB).   Call IHS if you have any further questions concerning the application.

APPLICANT NAME: Name of the person for whom the facilities will be constructed and to whom the facilities will be transferred

TRIBE & ENROLLMENT NO.: Federally recognized Tribe and Enrollment Number of the Applicant.  If Applicant is unable to provide enrollment information, belongs to a federally un-recognized Tribe, or is not enrolled, attach information to verify Native American heritage and Tribe name.  (An example of verification would be a letter from Applicant's Tribe, Applicant's name on the BIA California census rolls of 1928, Applicant's name on the 1950 or 1972 payment rolls, or proof that Applicant is a descendent of a person who appears on those rolls.)

MAILING ADDRESS: Current mailing address of Applicant.

FACILITIES LOCATION ADDRESS: Address or description of home where facilities will be constructed.  Use space provided to draw map, if necessary.

PHONE NUMBERS: Applicant's home phone and a phone number where IHS can talk to Applicant or leave a message for Applicant during the day.

SERVICES REQUESTED: Check space for desired services and provide information on past participation.

HOME INFORMATION: Applicant must complete all questions to the best of his or her ability.  Use "approx." if unsure of dates.  Construction of facilities is dependent upon information provided by Applicant.

MAP: Attach an assessor's parcel map from plat book, or a surveyor's drawing showing dimensions of home and lot, if possible.  If hand drawing a map, include dimensions, distances, directions, street and/or road names, color of house, or any other information pertinent to locating area for facilities construction.

APPLICANT RESPONSIBILITY:  This section outlines the responsibility of the Applicant and the disposition and transfer of the completed facilities.  

SIGNATURES: Applicant's signature (and landowner's signature, if different from Applicant's) will indicate Applicant accepts the responsibilities and provisions of the application.  Signature of Tribal Representative indicates Tribal Government is in accordance with Applicant's request for sanitation facilities.

QUESTIONS: If you have any questions regarding this application, please contact any of the offices listed below.  We are here to serve you.  Mail your application to the office that serves your particular county:


Butte, Glenn, Shasta, Tehama,
Modoc, Lassen or Plumas

Indian Health Service
Redding District Office
1900 Churn Creek Road, Suite 210
Redding, CA  96002
(530) 246-5339
FAX: (530) 246-5210

Humboldt, Del Norte,
Siskiyou or Trinity

Indian Health Service
Arcata Field Office
1125 16th Street, Suite 100
Arcata, CA  95521
(707) 822-1688
FAX: (707) 822-1692


Amador, Butte, Calaveras,
Colusa, Placer or Yolo

Indian Health Service
Sacramento District Office
650 Capitol Mall, Suite 7-100
Sacramento, CA  95814
(916) 930-3960
FAX: (916) 930-3954

Marin, Sonoma,
Mendocino or Lake

 Indian Health Service
Ukiah Field Office
1252 Airport Park Blvd. Ste. B5
Ukiah, CA  95482
(707) 462-5314
FAX: (707) 462-6907


Madera, Mariposa, Kings,
Fresno  or Tuolumne

Indian Health Service
Clovis Field Office
613 Harvard Ave., Suite 101
Clovis, CA  93612-1868
(559) 322-7448
FAX: (559) 322-7445


Indian Health Service
Porterville Field Office
2780 Yowlumne Ave., Suite A
Porterville, CA 93257
(559) 784-2715

Imperial, Riverside, San Diego
San Bernardino or Santa Barbara

Indian Health Service
Escondido District Office
1320 West Valley Parkway, Suite 309
(760) 735-6880
FAX: (760) 735-6893