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SAN JOAQUIN <br />—COUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit q: 12315 <br />Issued In county: County name <br />Chocolate Cldp Cookies Willi Walnuts <br />Sally Baker <br />123 Cottage Food Late <br />Anywhere. CA 90,%X <br />X <br />Ingredients: Enriched (tour (Wheat flour. nincnt. reduced iron. thiamine. <br />mononitrate, ribollavin and folic acid). butter (milk, salt), chocolate chips <br />(sugar. chocolate liquor, cocoa butte. butterfat (mil:), walnuts. sugar, eggs. <br />salt. artificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, mill:, soy. walnuts <br />Net Wi. 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 />lJ 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: C�LVF SU IDAJ <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.cdl3h.ca.gov/programs/Pages/fdbCottageFood.aspx <br />a of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />