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SAN JOAQUIN <br />COU N7Y <br />Environmental Health Department <br />Example: <br />BLADE IN .A HOME KITCHEN' <br />Permlt 8: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With walnuts <br />SalIv Baker <br />123 Conaae Food Lane <br />.grmvltere. CA 90'�\C <br />Ingredients: Emiched flour (NNgneat flour, niacin. reduced iron. duarime. <br />monmriante, riboflavin and folic acid). butter (mink. salt), chocolate chips <br />(sugarchocolate liquor. cocoa butter. bumlat Inulk). uvahmts, sugar. eggs. <br />salt. mtihcial vanilla extract, baking soda. <br />Contains: Wheat, eggs, milk. soy. urainuts <br />Net %A t. 3 oz. (85.049g) <br />Note: For the "Issued in County'- Identify the jurisdiction (city/county) where you ate obtaining approval. <br />6. Disposal of Waste: <br />Plea a 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 />Peas" <br />eas Identify the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: ib� 9-17)1 <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 ulster supply — check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: i <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 y t m tidbCottageFood m <br />4 of <br />