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Example: <br />MADE IN A HOME KITCHEN <br />Permit 4: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />12 Cottage Food Lane <br />An}nvhere, CA 90lL <br />Ingredients: Enriched flour (Wheat flour, piaci, reduced iron, thiamine, <br />mononitrate, riboflavin and folic acid), butter (milk- salt). chocolate clips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk). Walnuts, sugar, eggs, <br />salt, artificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, milk 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 />Pleas 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 <br />Department immediately. <br />7. Water Source: <br />MMPease dentify the water source to be used in Cottage Food Facility (check one box) <br />in 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 <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH websfte www.edph.ca.nov/programs/Pages/fdbCottageFood.aspx <br />EHO 16-276/27/22 4 CFO REG/PERMITTING FORM <br />