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SAN JOAQUIN <br /> <br />Environmental Health Department <br />Example: <br />\UDE IN .‘ HONIE KITCHEN <br />Permit a: 12345 <br />Issued in count: Count name <br />Chocolate Chip v ookies With Walnuts <br />Sally Bake! <br />123 ( 'ottage 1 ood Lane <br />.Nitywheie. CA ttiNNX <br />Ingredients: Enriched flout 'Wheat flour. niacin. reduced iron. thiamine. <br />inonomnate. rillotlavin and fillic acid a butter luta. salt). chocolate chips <br />sugiu. chocolate hquan. cocoa Num. huttei walnuts. sugar. <br />salt. adificial vanilla extract. baking soda <br />Contains: Wheat. eggs. milk. 'My. <br />Net NI t. 3 oz. (85.0490 <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 ePublic Sewer Service 0 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 />.[Z(Name of Public Water System or Community Services District: C `1 OF TRO G SI <br />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 />LI 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: NI 1 <br /> <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.qov/proqrams/PagesifdbCottageFood.aspx <br />o' 5