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SAN JOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />NLADE IN -A HOME KITCHEN <br />Permit #: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90=X <br />Ingredients: Enriched tlau (W7teat flour, ninciu. reduced iron. thiamhte. <br />momonimae. riboflavin and Colic acid), butter (hulk. salt). chocolate chips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), wahntts, sugair. eggs. <br />salt. artificial vanilla extract, baking soda. <br />Contains: Whem. eggs, milk, soy, walnuts <br />Net R1.3 oz. (85.049g) <br />Note: For the "Issued in County" - Identify the jurisdiction (city/county) where you am obtaining approval. <br />6. Disposal of Waste: <br />Pie e check what type of treatment is used to dispose of waste <br />ublic 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 />7e Identify the water source to be used in Cottage Food Facility (check one box) <br />ame of Public Water System or Community Services District: Ci�j 0 c skogion <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 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: L -C <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.cdvh.ca.gaylproomms/PageslfdbCottaGeFood.aspx <br />4 of <br />EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />