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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE ENA HOME KIT('HF\ <br /> Permit#: 12345, <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 1'?Cottage Food Lane <br /> Anywhere.CA 9011'\ <br /> Ingredients: Enriched flour(W7reat flour.niacin.reduced iron,thiamine. <br /> mononitrate.riboflavin and folic acid).butter i milk.salt).chocolate chips <br /> i,u,-ar.chocolate liquor,cocoa butter.buttertat i milk). \kahmts.sugar.egg,. <br /> ,alt.artificial vanilla extract,bakiug soda. <br /> Contains:Wheat.eggs,milk,soy.walnuts <br /> Net\\t.3 oz.(85.049-) <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 /> ,Xl_�ublic 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 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: C 1 tv <br /> ❑ Private Water Supply—, Identify the source (well, spring, surface, etc.): f ` <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 /> 0� <br /> Within 3 months of being approved to operate by the Environmental Health Department, please krovide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more information see CDPH website www.cdph.ca.aov/programs[Polaos/fdbCottaneFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />