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SANAOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HONIE KITCHEN <br />Permit ti: 12345 <br />Issued in counts- County name <br />Chocolate Chip Cookies \Pith Walnuts <br />snily Baker <br />123 Cottage Food Lane <br />Ansssitcrc. CA 9OXXX <br />Ingredients: ariched flour (\\\teat flan, nincin. reduced iron. ibinntine. <br />niononinmte. riboflnsin and folic ncid). Ismer (irink, salt). chocolate chips <br />(sugar. chocolme liquor. cocoa lamer. butterfat (nuik). ssmluuts, sugar. eggs. <br />salt. artificial smuilln extract. baking sada. <br />Contains: \Pleat, eggs, milk. soy, walnuts <br />Net 33't. 3 oz (85.0498) <br />Note: For the 'Issued in County' - Identity the jurisdiction (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 />LA <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: c6ul w ot+&V <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: <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 COPH website www.cdoh.ca.aovloroaromstPaaeslfdbCottaneFoW.asox <br />4of5 <br />