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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME ICITCHEN <br />Permit p: 12345 <br />Issued In Monty: County name <br />Chocolate Clip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90-1LGX <br />Ingredients: Enriched flog (Wheat 11om. niam reduced iron. thiamine. <br />nrononinate. riboflavin and folic acid). butter (milk, soli. chocolate clips <br />(sugar. chocolate liquor, cocoa butter. butterfat (milk). "whits. sugar, eggs. <br />salt. artificial vanilla extract. baking soda. <br />Contains: Wheat, eggs, mill:, soy, walnuts <br />Net Wt. 3 oz. (&5.049g) <br />Note: For the "Issued in County"- 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 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: Mountain House CSD, Inframark <br />❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): <br />Private Water Supply: Initial Water QualltyResults <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 wth local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: ke <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.edph.ca.aovlorouramsiPages/fdbCottaneFood.asox <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />