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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />\LADE IN a HO\IE KITCHEN <br />Permit #: 12345 <br />Issued In county: CouK name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Arnnvhere. CA 90NXX <br />Ingredients: Enriched flour (3l9reat flour, niacin, reduced iron, thiamine. <br />mononitrate, riboflaviu and folic acid). butter (silk. salt), chocolate chips <br />(sugar. chocolate liquor, cocoa better. butterfat (anile). walnuts, sugar. eggs. <br />salt. artificial vanilla extract, baking soda <br />Contains: IN -heat, eggs, milk, soy, walnuts <br />Net AN 1. 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 />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 />NaPe a Identify the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: C4 a" <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 y <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/urograms/Pages/fdbCotta-geFood.aspx <br />4 of <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />