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San Juan County Health Department
735 S 200 W Suite 2, Blanding, Utah 84511
Phone: 435-587-3838
sanjuanpublichealth.org
Septic Permit
Owner & Installer Information
Name of Owner:
Owner's Phone Number:
Owner's Email:
Installer's Name:
Installer's Phone Number:
Property Information
Address of Property:
Number of Bedrooms:
Is there a basement?
Yes
No
Is there a well on the property?
Yes
No
Soil Test and Plan Information
*This information will be provided to the Environmental Health Director by your Certified Wastewater Design Specialist
*All systems must be inspected by the Health Department before backfilling. Our Environmental Health Director will contact you shortly. However, if you have any questions feel free to call Dennis Shumway at 435-587-3838 Ext. 3505.
Applicant's E-Signature
Date:
Application Fees
Septic Permit:
$400.00
Item Subtotal:
$400.00
Total:
$400.00
Personal Information
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% additional service fee for foreign cards)
eCheck:
$0.75
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Payment method will be collected on external device
Change Payment Method
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Name of Owner:
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Name of Owner:
is required
Owner's Phone Number:
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Owner's Email:
is required
Installer's Name:
is required
Installer's Name:
is required
Installer's Phone Number:
is required
Address of Property:
is required
Number of Bedrooms:
is required
Applicant's E-Signature
is required
Date:
is required
First Name: is required
Last Name: is required
Address: is required
City: is required
State/Province: is required
ZIP/Postal Code: is required
Phone: is required
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