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SANJ O A Q U ( N Environmental Health Department <br /> ---COUNTY--- <br /> Example: <br /> J <br /> -` MADE 1N:1 HOME KITCHEN <br /> Permit=: 12345 <br /> Issued in counts: Counts name <br /> Chocolate Clup Cookies With Walnuts <br /> sant'Baker <br /> 123 Cottage Food Lane <br /> Anywhere.C_190-VCC <br /> Ingredients: Enriched flour(1111eat flour.niacin,teduced iron.thiamine, <br /> nionouinate,tiboflas m and folic acid),buffet(nulk,salt).chocolate chips <br /> (sugar.chocolate liquor.cocoa butter.butterfat(milk). "alnuts,sugar,eggs. <br /> salt.artificial vanilla esnact,bikutR soda. <br /> Contains:Wheat,cans.milk,soy,walnuts <br /> Net\A t.3 oz.(55.0498) <br /> Note:1=oi f,`]e'issued in County"-idep t.+(V the unsdiclboi?(City/county')where you av obtairing approvai. <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 ssrtem failure or plumbing problem, y)u are required to rr,bf;r San Joaquin County Environmental Health Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Foot!Facility(check on/e�box) <br /> Q Name of Public Water System or Community Services District: Q)" <br /> ❑ Private Water Supply', Identify the source(well, spring, surface, e c): <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 /> "Adchbonal information may be required if food is prepared from a home with a private water supply—checkwith local jurisdiction. <br /> 8. Food Processor Course-. Initial if you agree to abide by the following;L L_ <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 /> Formore information see.=DF'H vieb=rite wvvw.cdph.ca.gov/programs[Pages/fdbCottageFood.aspx <br /> EHD 16-27 6;29117 CFO REGiPERMITTING FORM <br />