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San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
sanjuanpublichealth.org
Application for Child Care Food Service Inspection
*Completed application and fee of $30.00 must be received before an inspection will be scheduled.
Applicant's Information
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Child Care Food Service Inspection:
$30.00
Item Subtotal:
$30.00
Total:
$30.00
*Inspection is by appointment only. Please allow up to 5 (five) business days for completion of inspection.
Our Environmental Health Director will contact you to schedule an inspection.
Type of Inspection Requested:
Licensed Family
Licensed Family Group
Residential Certificate
Signature of Applicant
Date
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% surcharge 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:
Change Payment Method
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