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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />\LADE IN A HOME KITCHEN <br />Permit ft: 12345 <br />Issued In county: County name <br />Chocolate Clip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />_4uynvhere. CA 90..=X <br />Ingredients: Enriched flour (Wlrent flour, miacim, reduced iron, thiamine, <br />mononitmte, riboflavin and folic acid). butter (milli salt), chocolate chips <br />(sugar. chocolate liquor. cocoa butter, butterfat (milk), walnuts, sugar, eggs, <br />salt mlificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, mill; soy, 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 of waste <br />3e 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 />1X1 Name of Public Water System or Community Services District: C; hi q L,64A <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 maybe required if food is prepared from a home with a private water supply—check with local junsdiction. <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.cdoh.caoov/mrooramsfpaeesifdbCottaaeFood.asox <br />4 of <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />