San Juan County Public Health

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San Juan County Health Department 735 S 200 W STE 2, Blanding, UT, 84511 Phone (435) 587-3838 https://sanjuanpublichealth.org/

Application For Mass Gathering Permit

Event Coordinator's Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Event Name

Location of Gathering

Dates & Times of Gathering

Purpose of Gathering

Number of People Expected to Attend

Peak Number of People Expected

Estimated Length of Stay of Attendees

Name of Property Owner

Address of Property Owner

Phone Number of Property Owner

Site Clean Up Plan

Plan for Directional and Exit Signs

Plan to address nuisances or health hazards associated with animals present at the gathering:

Plan to address hazardous conditions

*Plan to address hazardous conditions, including but not limited to evacuation, cancellation or delay of the gathering and provisions for support facilities

Number of Food Vendors Expected

Have you notified Food Vendors of required permits

		Yes
		No

Name of Solid Waste Haulers

Phone #

Name of Liquid Waste Haulers

Phone #

Total Number of Emergency Medical Personnel & Qualifications

* Submit a site plan delineating the area where the gathering is to be held, including the following: 1. The parking area available for patrons; 2. Location of entrance, exit, and interior roadways and walks; 3. Location of all first aid stations and emergency medical resources; 4. Location, type, and provider of restroom facilities; 5. Location and description of water stations; 6. Location and number of food stands, and the types of food to be served if known; (separate food booth permits are required for each vendor) 7. Location, number, type, and provider of solid waste containers; 8. Location of operators headquarters at the gathering; 9. L plan to provide adequate lighting to ensure the comfort and safety of attendees and staff; 10. Location of all parking areas designated for the gathering and under the operator's control; 11. Provisions for allowing health inspectors onsite *Please send your site plan with the above information to publichealth@sanjuancounty.org*
Signature of Applicant
Date

Mass Gathering Permit:

$605.00

Item Subtotal:

$605.00

Total:

$605.00

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


Submitting ... 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 Email: is required Event Name is required Location of Gathering is required Dates & Times of Gathering is required Purpose of Gathering is required Number of People Expected to Attend is required Peak Number of People Expected is required Estimated Length of Stay of Attendees is required Name of Property Owner is required Address of Property Owner is required Phone Number of Property Owner is required Site Clean Up Plan is required Plan for Directional and Exit Signs is required Plan to address nuisances or health hazards associated with animals present at the gathering: is required Plan to address hazardous conditions is required Number of Food Vendors Expected is required Name of Solid Waste Haulers is required Phone # is required Name of Liquid Waste Haulers is required Phone # is required Total Number of Emergency Medical Personnel & Qualifications is required Signature of Applicant is required Date is required You must enter a payment method.


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