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SAN JOAQUIN <br />O l.J N T Y ._....-.. <br />Environmental Health Department <br />Example: <br />VIADEINA lionAII?KIIf HI:N <br />Permit q; 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />12" Cottage Food Lane <br />Annzyhere. CA 9USSS <br />Ingredients: Enriched flan (R'beat flour. niacin. reduced iron. thianrine. <br />mononitrate, rihoflnvin and folic acid). bnner (milk. snitl. chmolate chips <br />(sugar. chocolate liepron. cocon butte. butterfat (milk). walnurs, sugar. eggs. <br />salt- artificial vanilla extram baking soda. <br />Contains: Wheat, eggs. milk, say, walnuts <br />Net Wt. 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 off waste <br />21 --private <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 />F1 Name of Public Water System or Community Services District: <br />2 Private Water Supply", Identify the source (well, spring, surface, etc.): w��1 <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 />Ei BBacteriological Test (quarterly'): Tt�k aux11 ,,,,'' . , J _ _► <br />Y Nitrate Test (yearly`; 1� ! I�lddd U <br />Nitrite Test (every 3 <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: OF- <br />Within <br />F <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.aovlprograms/PaaeslfdbCottaneFood.asp <br />4 of <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />