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SANAUQUIN <br />—COUNTY— <br />A <br />Environmental Health Department <br />Example: <br />MADE IN A NONIE KITCHEN <br />Perutll 4: 12345 <br />Issued in counly: Counte name <br />C1locolnte Chip Cookies With \Vnlnuts <br />Sally Baker <br />123 Cottage Food Intoe <br />An)% iiere. CA 90X%% <br />Ingretllents: Enriched nonr (Wheat fiomt niacin, reduced iron, lhinmine. <br />mononitrate, ribofirwin and folic ncid). butter (milk, snit), chocolate chips <br />(sugar, chocolate liquor. cocoa butter, butterfat (milk), aahuds, sugar- eggs. <br />sail, artificial lnuilla extinct, bakine soda. <br />Contains: Whent, eggs, milk, soy, walnuts <br />Net Wt. 3 oz (85.0498) <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 />Public 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: (tel IV e 6 / /� I.'I11)tcA <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 two is prepared from a home with a private water supply — check with local jurisdiction. <br />8. F od 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 mbsite www.cdph.ca.govlprograms/Pages/fdbCoftacieFood.esP <br />4 of <br />EHD 16-27 6/29/17 CFO REG/PERMnTING FORM <br />