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: