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SANA0A0UIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />\MADE IN A HOINIE KITCHEN - <br />. Permit 8: 12345 <br />Issued In county: County name' <br />Chocolate Chip Cookies with walnuts <br />Snlly Baker <br />123 Cottage Food Late <br />Anywhere. CA 90XSX <br />Ingrollehts: Enriched Flour (wheat flour, niacin. reduced iron. thiamine. <br />.mononitnve. riboflavin and folic ocid), butter (milk, salt), chocolate chips <br />(sugar. cltocolmeliquor, cocoa butter, butterfat (milk); walnuts: sugar. eggs. <br />snit, nnificial vanilla extract. bakiing soda. <br />Contains: %illeat, eggs, milk, say, walnuts <br />Net IN'L 3 oz. (85,049g) <br />Note: For the "Issued in County' - Identify the jurisdiction (citylcounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />t% 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 Department <br />Immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />9 Name of Public Water System or Community Services District: GI:N Mk-,rbn WNCK <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 Slate 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 y <br />••Additional information maybe 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: " � d_ <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 <br />(CDPH) food processor course. <br />For more information see CDPH website www.cdvh.ca.aoWDroarame/Penes/fdbCottageFood.asi) <br />4 of <br />EHD 16-27 6129117 CFO REGIPERMITTING FORM <br />