San Juan County Public Health
             
San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
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:   $500.00   Item Subtotal:  
$500.00
Total:
$500.00
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:
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