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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />MADE INA HOME M"('IIE� <br />hrmne: 1.5 <br />I—e 11. a m, ('mon Come <br />(trcoL n CWp Cookies tti@ Nbbnre <br />Sopv Bda <br />tvhceC "Luis <br />iurxLneC.i vm�M <br />IvRmlimn: EmelwJ llgv lNtleu llwu.Itixw.IMrN llm.11uruurs. <br />e. nlutlm'in and foci. rviJ). Lunn uui@. xle. char&¢alms <br />Iwgni'daMrlm lxpnn. rolxwa. Un1a611oiRl. ndum>>uem. eyes. <br />ah. mi&ullmllontmel. lmYilre � <br />Caeltlau A M4 eR{t ntlLL. mS. � ory <br />�w A'4l or. (eSODp <br />ade: Fm llre'Isalatl in CWMy'-Icklp/y (lellna.%Tian (cilykvuMy) n1.e/e yW ale oMainmp arpmval <br />S. Disposal of Waste: <br />Pleas heck what type of treahnentis used M tlispess of waste <br />ublic Sewer Service ❑ Private Septic System <br />In the went of mie c system tadum a plumNnp "Won, you are hemmed to lmfiry sen Jaequln Comity Errvirolmellbl Heahh uepmmem <br />knrhmffo ey. <br />7. Water Souree: <br />Pease nbly this watersoume M be used in Cottage Food Facility (check one box) <br />M111ame of Public Water System or Community Services District: 1.`O 'i ix re p I'uLl,2 `4- <br />❑ Private Water Supply", Identify the source (well, spring, surface, eco.): <br />f ate IM" Supply. Initial waer Quality Resubs <br />Check boxes below if initial weter testing has been completed. <br />All testngmustbadone ate Siete Germed tabomtory. Bl ra chkbme itsofpmvidemmeeWb,dete8 <br />results in space provided reed to type of test <br />'(iesbng frequency far tfansieed NonCommunM Witter Systems alter Initial testing) <br />❑ Bacteriological Test (quarterly'): <br />❑ Nitrate Test (yeady'): <br />❑ Nitrite Test (every 3 years'): <br />–Atltlmwal momWM may W relNrm n bmd is preened hem a Mme eith a er—le weler supply–chwk»ith local luromeion. <br />B. Food Processor Course: Initial ti you agree to abide by the following: ` ' VV%, <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 hqm lhrmemon see CDPH we ?m" ed - — ntl Footl_o <br />4of5 <br />.no 16 -yr 3911, CFO PEdPERMiTTIrr: FORM <br />"tiicyJ— <br />