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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />NLADE I7 A HOME KITCHEN <br />Permit #: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Waluuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. Ca 90VLX <br />Ingredients: Enriched flour (Wheat flotu, niacin, reduced iron, thiamine. <br />mononitrate, riboflavin and folic acid), butter (milk, salt), chocolate chips <br />(sugar. chocolate liquor, cocoa butter, butterfat (hulk). walnuts, sugar, eggs. <br />salt, artificial vanilla extract. baking soda. <br />Contains: teat, eggs, milk, soy, Srainuts <br />Net '%Vt. 3 oz. (85.049g) <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 />0 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: C fTy 0.F LAT �ko'p <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: J <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 more information see CDPH website www.cdph.ca.ciov/programs/Pages/fdbCottageFood.aspx <br />4of5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />