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Example: <br />MADE IN A HOME KITCHEN <br />Permit N: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90X. <br />Ingredients: Enriched flow (Wheat flour, niacin, reduced iron, thiamine, <br />mononihate, riboflavin and folic acid), butter (mill:, salt), chocolate clips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts, sugar, eggs, <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 />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />K Public Sewer Service <br />❑ 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: 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 />❑ 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:JT <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.gov/programs/PagesifdbCottageFood.aspx <br />EHD 16-271/6/2014 3 CFO REG/PERMITTING FORM <br />