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SANJOANIN <br />COU NTY <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 Laue <br />Anywhere. CA 90,= <br />Ingredients: Enriched flour (Wheat flora, niacin. reduced iron. thiamine. <br />mononitrate. riboflavin and folic acid). butter (mill:. salt), chocolate chips <br />(sugar. chocolate liquor. cocoa butter. butterfat (null:). walnuts. sugar. eees. <br />salt. artificial vanilla extract. bakine soda. <br />Contains: 'Wheat, eggs, milk, sop, walnuts <br />Net RT. 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 />Please check what type oftrea/tr�lant is used to dispose of waste <br />�7Public Sewer Service / El Private Septic System <br />In the event of septic system failu✓re 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 />�7Name of Public Water System or Community Services District: - -F, <br />❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): 1 <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.cdoh.ca.aovloroaramsfPaaesffdbCottaneFood.asox <br />4 of <br />