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SAN JOAQUIN <br />)U NTY— <br />Environmental Health Department <br />Eyarnple: <br />�1ADE IN A Hoi\IE KITCHEN <br />Perndt ff: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With WAIluas <br />Sally Balser <br />123 Cottage Food Lane <br />Auvschere, CA 90-%XK <br />Ingredients: Emiched flour Oklwat floor, maciu. reduced iron, dtiatuitre. <br />monooinale, riboflavin and folic acid), Moret (milk. soil). chocolate chips <br />(sugar. chocolate li(puor, cocoa Mmes. butterfat Imi&). walnms. stlgv. ecus. <br />salt, artificial vanilla extract. baking sola. <br />Contains: Wheat, eggs, mill" soy, walnuts <br />et Wt. 3 oz. (85.0499) <br />Now For the "Issued In County'- Identity the jurisdiction (cVfttinty) where you are obtaining appmvel <br />6. Disposai of Waste: <br />Please check what type of treatment is used to dispose of waste <br />� <br />Public Sewer Service <br />❑ Private Septic System <br />In the event of septic system failure or plumbing problem, you are required to notify San Joaquin County Environmental Health Department <br />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />Q NMOUNTAIt4 HOUSE COMNUNIVame of Public Water System or Community Services District: SF o tc ei DIS 121 T <br />[_1Private Water Supply`*, Identify the source (well, spring, surface, etc.): <br />Private Water Supply: Initial Water Quality Results <br />Check boxes below if initial water testing has been completed. <br />All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab, date & <br />results in space provided next to type of test. <br />'(Testing frequency for transient Non -Community Water Systems after initial testing) <br />❑ Bacteriological Test (quarterly'): <br />❑ Nitrate Test (yearly'). <br />❑ Nitrite Test (every 3 years'): <br />—Additional information may be required if food is prepared from a home with a private water supply - check with local jurisdiction. <br />8. Food Processor Course: Initial If you agree to abide by the following: _ S <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />of completion of the California Food Handicr course in lieu of the California Department of Public Health <br />((;DPI f) food processor course. <br />For more information see MPH website Zvww_csfph_w,goLlpr49rainsP-agestfdbCottaaaFood_a� <br />4 of <br />EMD 16-27 6129117 CFO REGIPERMITTING FORM <br />