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San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
sanjuanpublichealth.org
Swimming Pool/Spa (Hot Tub) Permit
*Application and payment must be received before permit is issued*
Facility Name
Facility Address
Phone Number
Owner / Manager
Mailing Address
Phone Number
Email Address
Spa location
Indoor
Outdoor
Operating
Seasonal
Year Round
Certified Pool Operator
CPO #
Date Issued
Date Expires
**PLEASE ATTACH A COPY OF THE CERTIFIED POOL OPERATORS CERTIFICATE HERE**
Applicant agrees that maintenance of a health permit is predicated on compliance with Utah Code R392-302 (Swimming pool design, construction and operation of public pools). This permit is nontransferable and revocable for noncompliance. Permit is valid for one year from date of issue.
Signature
Date
Permit Fee:
$100.00
Item Subtotal:
$100.00
Total:
$100.00
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
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Facility Name
is required
Facility Address
is required
Phone Number
is required
Owner / Manager
is required
Mailing Address
is required
Phone Number
is required
Email Address
is required
Certified Pool Operator
is required
CPO #
is required
Date Issued
is required
Date Expires
is required
Signature
is required
Date
is required
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