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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 flour (Wheat flour, niacin, reduced iron, thiamine. <br />mononitrate, riboflavin and folic acid), butter (milk, salt), chocolate chips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts. sugar, eges, <br />salt, artificial vanilla extract, baking soda. <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 />Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />El Public Sewer Service ErPrivate Septic System <br />In the event of septic system failure or plumbing problem, you are required to notify San Joaquin County Environmental Health <br />Department immediately. <br />Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />IE Name of Public Water System or Community Services District: cal" O-F 57 -Pc-ion k,41-75.t We/0- <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 />El Bacteriological Test (quarterly*): <br />I=1 Nitrate Test (yearly*): <br />El 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 />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 <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdph.camov/proarams/Pages/fdbCottageFood.aspx <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM