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SAN J O A O U I N Environmental Health Department <br /> Example: <br /> MADE INA HO\IE KITCHEN <br /> Prrmll al "It <br /> l++utd In taunly: Caumy nnmt <br /> I hocalale(lup(nitln Nldl lihhum <br /> Sally LIAn <br /> 123('+males Rnxl Ifile <br /> Anvil ne.CA e(IXXX <br /> IaIImlkah: 7mu•hal ILau Il1'hrm Iloul,Watul.mfucol 11441 1111,1111111 <br /> 144aaa1111a1C.111xIgaC111 alai 11111C Will Wass(II014.Will).11kV. 1C dill" <br /> IHIy1R flxxvlair liquol,cmim Wass.Iaincifai I1mlA1 WWa1ooh, +Oral.CPVI <br /> +all.mhf chol sntulla ewatl.I. Amt Yk61 <br /> ('oat hints:N bah e)tll+,MUk.+oy,rtslouh <br /> Nrl q 1.3 01.110.049a) <br /> bbg(L For mo'Issued in County'-Idenbly tholunici coon(cdy/counly)where you aro obtaining approval <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ®`Public Sewer Service ❑ Private Septic System <br /> In the event of septic system fi llurn or plumbing problem,you are rnpured to nobly San Joaquin County Envimnmontal Hpanh Depanmmnl <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: C}% OF L04li1mP UiI h k%e% <br /> ❑ Private Water Supply", Identify the source(well, spring, surface, etc.): <br /> Prfvato Witter Supply. Initial Water Quality Results <br /> Check boxes below if Initial water testing has been completed <br /> All testing must be done at a Stale Certified laboratory Either attach lab results or provide name of lab,date 8 <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 bo required it food is prepared from a home Willi a prNato wator supply-chock will lucel iunsdanon <br /> 8. Food Processor Course: Initial if you agree to abide by the following: C- <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 Bee CDPH wrbsae cd h ca v/ 1Pa eslfdbCott eFood.as x <br /> i <br /> Esu leh'Ii49rl r CFO REOIPERMITTINO FORM <br />