San Juan County Public Health
             
San Juan County Health Department
735 S 200 W Suite 2, Blanding, UT 84511
Phone: (435) 587-3838

Water Sample
NOTE: Our Environmental Health Director will contact you about your application to arrange a time to take the water sample. If you would like to take your own water sample please go back to our website and choose the self-service option. If you have any questions please contact Ronnie Nieves at (435) 587-3838. 


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

Date
Owner Name
Contact Phone Number
Address of sample location
City of sample location
 
*There will be a travel surcharge of $0.56 per mile round trip (for a total of $1.12 one way) from our office in Blanding for ALL APPLICANTS.
**Please enter the number of miles from the site of water sampling to our office in the quantity box below. This should ONLY be blank if you live within one mile of our office.

For Example, if your sample will be taken at a location 20 miles from our office please enter "20" in the Travel Surcharge quantity box below.
Click HERE to find the mileage from your property to our office for the travel surcharge. This will use your current location if you are at your property. If you are not, please enter your address instead.

Sample Charge:   $30.00   Quantity:   Item Subtotal:  
$30.00
Travel Surcharge:   $1.12   Quantity:   Item Subtotal:  
$0.00
Total:
$30.00
 
Payment Information:
Processing Fee Rates:
Cards:2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:$0.75
Method of Payment:
 Update Name from Personal/Organizational Information
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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