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SAN_JOAQUIN <br />=0U NTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit q: 12345 <br />Issued in county: Ccwnty same <br />Chocolate Cbip Cookies With Walnuts <br />Sally Baker <br />123 Corage Food Lane <br />A" here. CA 9o7Da <br />Ingtedlents: Fiuiched tiom (Whast flour. inKni. reduced iron. thianuue. <br />ruouctarnale, riboflavin and folic acid), butter (mik salt). chocolate chips <br />(sugar. chocolate liquor, cocoa butter, butterfat (milk). walnum sugar, eggs. <br />snit, artifatial vanilla extract baling soda. <br />Contatas: Wheat, eggs, milk, am•, walaata <br />Set Wt. 3 ox. (85.649g) <br />Note: For the 'Issued in County"- Identify the jurisdiclion (city/county) 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 ❑ 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 />cPease Identify the water source to be used in Cottage Food Facility (check one box) <br />pD Name of Public Water System or Community Services District: Cis4 t}. ShC IGk F l <br />✓❑Private Water Supply", Identify the source (well, spring, surface, et <br />Private Water Supply: Initial Wafer 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: V6 <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 wvew.t doh.ea.aovlo amms(PaaesmbCottaaeFood.asux <br />4 of <br />EHD 1647 6129117 CFO REGIPERMITTING FORM <br />