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Example: <br /> Nil IN.A HOME HITCHEN <br /> Permit q: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 1?;Cona_¢e Food Lane <br /> Auvwhere.CA 90-` CK <br /> Ingredients:.Enriched flour(Wheat floru,muciu,reduced iron.thiamine. <br /> ntonrinihate,riboflavin and Folic acid).butter(milk,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa buttery,butterfat(milk), walnuts,swear,esss. <br /> salt_artificial vwilla extract,baking sola. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz(85.0498) <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 /> 19 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 <br /> Department immediately. <br /> 7. Water Source: <br /> Peale Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: CLJYD 6t max*(!-� <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 /> ❑ 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: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> " provide proof of completion of the California Food Handler course in lieu of the California Department <br /> of Public Health (CDPH)food processor course. <br /> For more information see CDPH website www.cdoh.ca.aov/oroorams/Paoes/fdbCottaoeFood.asox <br /> EHD 16-277/27/17 4 CFO REG/PERMITTING FORM <br />