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SAN J0AQUIN <br />Y <br />Environmental Health Department <br />Example: <br />NUDE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued In county: County name <br />Chocolate Chip Coolies With Walnuts <br />Sally Baker <br />133 Cottage Food Lane <br />Anywhere, CA 903OCK <br />Ingredients: Enriched flow (Wheat flan, niacin. reduced iron. thimume, <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: Wiest, eggs, milk, soy, walnuts <br />Net Wt 3 oz. (85.049g) <br />Note: For the "Issued in County"- Identify the jurisdiction (citylcouniy) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />Public Sewer Service <br />❑ 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 />Name of Public Water System or Community Services District: G M () 7_ G <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: M <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 (CDPH) <br />food processor course. <br />For more information see CDPH website www.cdoh.ca.aovloroaramslPaaeslfdbCottaneFood.asox <br />4 of <br />