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SAN JOAQUIN <br />C C'1(1NTY <br />Environmental Health Department <br />Example: <br />\LADE FNA HOME KITCHEN <br />Permit a: 12345 <br />hwed In counts: C'ounis name <br />Chocolate Chip Cookies P'nh 1Cnlnuls <br />Sall), Baker <br />12? Conaae Food Line <br />Ansyshere. CA 9nN.CC <br />Ingrnllents: Eunched flow (Uheat flour. ruacur. reduced uon. duauune. <br />nrauonmale. nlrofiaym and folic ncid). buner (milk, sal). chocolate chips <br />(sngs. chocolate liquor. cocoa honer. hunelfal umlk). r% alnuls. sm_m. tees. <br />,all. artificial cmrilla extract. bakinz sats <br />Contains: \Cheat, eggs, milk soy, walnuls <br />Net %%1.3 oz (85.819g) <br />Note: For the 'Issued in County"- Identify the jurisdiction (city/county) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <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 />Name of Public Water System or Community Services District: ,+ JO%� J J n.>t,� I Jb� l� <br />E] Private Water Supply", Identify the source (well, spring, surface, etc.): —7 CI>Q IVso <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, dale & <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 y <br />"Additional information may be required if food is prepared from a home with a private weler supply — check wim local Jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />of completion of the California Food Handler course in lieu of the California Department of Public Health <br />(CDPH) food processor course. <br />For more information see CDPH website www.cdph.ca.povloroarams/PaeeslfdbCottaaeFood.mpx <br />4 of <br />EHD 18-278/29/17 CFO REG/PERMIrnNG FORM <br />