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SAN JOAQUIN <br />COUI',ITY— <br />Environmental Health Department <br />Example: <br />AUDE LN A FIOME IOTCHLN <br />Permit 12345 <br />Issued in counts County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Coulee Food Laue <br />AuYrvlrere, CA 90XXX <br />Ingredients: Enriched flour (\4'heat flour, niacin. reduced iron, tlrianriue, <br />monouihate, riboflayhn and folic acid). butter (mill:, salt). chocolate chips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), wahnns. swear, cess. <br />salt. artificial sauulla extract bilins soda. <br />Contains: RLeat, eggs, mill:, soy, walnuts <br />et Wt. 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 />Pie e check what type of treatment is used to dispose of waste <br />Public Sewer Service E] 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) C 1 <br />Name of Public Water System or Community Services District: <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 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.gov/programs/Pages/fdbCottageFood.aspx <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />