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SAN 10AQUIN <br />COUNT <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: ,12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90..= <br />Ingredients: Enriched flow' (Wheat flour, niacin. reduced iron. thiamine. <br />mononitrate, riboflavin and folic acid). butter (milk, salt). chocolate chips <br />(sugar. chocolate liquor, cocoa butter, butterfat Gnilk). walnuts. sugar. eggs. <br />salt. artificial vanilla extmct. baking soda. <br />Contains: wheat, eggs, milk. soy, walnuts <br />Net R't. 3 oz. (85.049g) <br />Note: For the "Issued in County" - Identify the jurisdiction (citylLounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of tyaste <br />El 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 />❑ Name of Public Water System or Community Services District: <br />Private Water Supply", Identify the source (well, spring, surface, etc.): W � <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 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 />IV— <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />of completion of the California Food Handier course in lieu of the California Department of Public Health <br />(C DPH) food processor course. <br />For more information see CDPH website www.cdph.ca.aovloroarems/PauesmbCottaaeFood,asckx <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />