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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)M <br /> Ingredients: Enriched flow(Wheat floor,niacin.reduced hon,thiamine. <br /> monouitmte,riboflavin and folic acid),butter(mik salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa burro.butterfat(milk), walnuts,sugar,eggs, <br /> salt.artificial vanilla extract,balling soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz(65.049g) <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 of treatment is used to dispose of waste <br /> ® Public Sewer Service ❑ Private 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: City of Stockton <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 H food is prepared from a home with a private water supply—check with local jurisdiction. <br /> B. Food Processor Course: Initial if you agree to abide by the following: GD <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.cdoh.ta.aovlpro-gmmslPagesMdbCottaneFOod.asox <br /> END 16475/3/2013 3 CFO REG/PERMITTING FORM <br /> EHD 16-27 5/312013 4 CFO REG/PERMITTING FORM <br />