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SANJ O A Q U I N Environmental Health Department <br /> i COUNTY <br /> Example: <br /> MADE INA 110\IF.KI1 CHEN <br /> Permlt 0: 12345 <br /> Issued in count%: Counh name <br /> Chocolate Clip Cookies With\\',1111111, <br /> Sally Baker <br /> 12 1 Conage Rxxl Lane <br /> A.ymbere.CA 90XX-\ <br /> Ingredlenrs: Lmrelml floru ovhcar(low,11mcnt.reduce(I iton.iluanunc. <br /> tnonownale.ritx flacm and folic acid).bullet(nulk.%.alit,chocolate cluln <br /> tsugar,eliocolate liquor.cocoa buos7.burterlal mulk). waluuh.sugar.eggs. <br /> salt,artificial s;andla exn,Kt bekma saki <br /> Contains:Wheat,eggs,mllk,sny,walnuts <br /> Nei\\1.3 oz 185.049g► <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 /> ,, <br /> Public Sewer Service ❑ 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. T)Q 7/ 1Q <br /> El Private 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 Handler course in lieu of the California Department of Public Health(CDPH) <br /> food processor course. <br /> For more information see CDPH website www.cdph.ca.govlprograms/Pages/fdbCottage Food.as lax <br />