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Example: <br /> -NLIN a HOME KITCHEN <br /> Permit 0: 12345 <br /> Issued In count-: C'ounpr name <br /> Chocolate Chip Cookies With Waluuts <br /> Sally Baker <br /> 12.33('ounge Food Lane <br /> Ari ns'itere.CA 40)--IX <br /> Ingredients: Enriched flour(Wheat flour niacin,reduced iron,thiamine, <br /> omnointmte,ti ohm io and folic acid),buret(milk,salt).chocolate ghat!, <br /> (sugar.choccda a liquor.cocoa butte'.butterfat(mill:)- walnuts.sugar,eggs. <br /> salt,artificial vauilhr extract,baking soon, <br /> Contains:Wheat,eggs,mill:,soy,walnuts <br /> Net Wt.3 oz(85.0490 <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 of treatment is used to dispose of'waste <br /> ❑ Public Sewer Service t 1 t'rivate 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 /> 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: <br /> = -- ------------ <br /> ❑'Vrivate 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 /> '(Tesfing frequency for transient Non-Community Water Systems after initial testing) <br /> ,8'facteriological Test(quarterly'): <br /> Nitrate Test(yearly'): <br /> Nitrate 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 fallowing: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> provide proof of completion of the required California Department of Public Health (CDPH)food <br /> processor course. <br /> For more information see CDPH website www.cdph.ca.ilovlprWrams/Pages/fdbCottageFood.aspx <br /> EHD 16.2712127/2012 3 CFO REG/PERMITTING FORM <br />