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SAN-JOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME IMCHE\ <br />Permit 8: 12345 <br />Issued In county: County eane <br />Chocolate Chip Coolies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />AWwlrere. CA 90A'k'\ <br />Ingredients: Enriched flora (Wheat flow. uiacm. reduced iron. tluamme. <br />mou a mue. riboflavin and folic acid). butter (mill-. salt). chocolate chips <br />(sugar. chocolate liquor. cocoa butter, butterfat (milk)_ walnuts. sugar, egg, <br />salt. artificial ,:vu0a extract baking soda. <br />Contains: Wheat eggs, milk. sour Walnuts <br />Net Wt. 3 oz (IM5.049g) <br />Note: For the "Issued in County" - Identify the jurisdiction (chylcounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Ple se check what type of treatment is used to dispose of waste <br />Public Sewer Service El Private Septic System <br />Z <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: <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.rdph.ra.aodorogr s/Pages/fdbCottaneFood.asox <br />4 of <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />