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SAN JOAQUIN <br />—COU N -Y -- <br />Environmental Health Department <br />Example: <br />NUDE IN A HOME KITCHEN <br />Permit fl: 12345 <br />Issued in county: County name <br />Chocolate Clap Cookies With Walnuts <br />Sally Baker <br />123 Conage Food Lane <br />Atrywhere. CA 90%"X.\ <br />Ingredients: Enriched flour (Wheat flow, taaciu, reduced iron. tluatrmre. <br />mouonimate. riboflavin and folic acid), butter (milk, salt). chocolate claps <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts, sugar, eggs, <br />salt,artificial vanilla extract, baking sodn. <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 />PI ase check what type oft atment is used to dispose of waste <br />Public Sewer Service yf/ ./ / F1 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) n <br />Name of Public Water System or Community Services District: ��„/Y�./ r /j " <br />[I Private Water Supply**, Identify the source (well, spring, surface, etc.): "I N -r <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 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.cdnh.ca.gov/programs/Pages/fdbCottaneFood.asl)x <br />4 of <br />