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SA610AQUIN <br />COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit 8: 12345 <br />Issued In mune: County name <br />Cbocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Arnmlme. CA 90MCX <br />Ingredients: Enriched flour (Wheat flour, niacin, reduced iron. thiamine, <br />mononitrate, riboflavin and folic acid), butter (milk, salt), chocolate chips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts. ts. sugar, eggs, <br />salt. artificial vanilla extract. baking soda. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net NVL 3 oz (85.0499) <br />Note: For the 'Issued in Count/ - Identify the jurisdiction (city/county) where you am obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />® Public Sewer Service <br />❑ Private Septic System <br />In the event of septic system failure or plumbing problem, you are required to nobly 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: City of Stockton <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 />'(Tesfing 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: NAII <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.cdoh.ca.aovbroaramslPapestfdbCottageFood.aspx <br />4 of <br />EMD 1627 629/17 CFO REWlPERMITTING FORM <br />