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SAN10 A Q U I N Environmental Health Department <br /> - -CoUN7V <br /> Example: <br /> NUDE IN a HOME KITCHEN' <br /> Permit M: 12.45 <br /> Issued In county: County name <br /> Chocolate Chill Cookies R'ith Walnuts <br /> Salt,Baker <br /> l_'?Cottage Food Iaae <br /> A ny%%inere.CA 90.VL <br /> Ingredients: Enriched flotu(Wheal flour.matin.reduced troll.thiantim. <br /> mononitrate.niboflavin and folic acid).butter(m&salt).chocolate chips <br /> I SLIg:II,chcx-olate liquor,cocoa batter.butterfat(milk). walntnts_sugar.eggs. <br /> salt.vlificial eauilla extract.baking soda. <br /> Contains:FR-beat.eggs,milt:,sop,walnuts <br /> Net R't.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 /> Xpublic 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: Oto Of <br /> ❑ Private Water Supply", Identify the source(well,spring, surface, etc.) T <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 infomnaWn may be required H 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 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 cam!°r°°�m�aeesH�CottaaeFood nox <br /> 4 of 5 CFO REGIPERMITTING FORM <br /> EHD 16-27 6/29117 <br />