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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />NUDE IN A HOME IaTCHEN <br />Permit rl: 12345 <br />issued In county: County name <br />Chocolate drip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Amnvhere. CA 90.]OLX <br />Ingredients: Enriched flan Mlreat flour. niacin- reduced iron Thiamine. <br />mononitrate. riiwflayiu and folic acid). Ironer nuilk sa10. chocolate clips <br />(sugar. chocolate liquor. cocoa boner. Inmerfat unilk). walnuts. its. sugar. eggs. <br />salt. artificial Vanilla extract, baking soda. <br />Contains: Wheat. eggs, milk say. walnu6 <br />VN Wt. 3 oz (95.049g) <br />Note: For the -Issued in County-- Identify the jurisdiction (cirylcounly) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />RrPublic 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 Department <br />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />YEJ Name of Public Water System or Community Services District: `7 <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc.): r <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 nett 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 may be required g 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: e) ( <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.cdoh.cawWprourams/P**WdbCottaaeFood.aspx <br />4 of 5 <br />EHD 1627 &12WI7 CFO REGIPERMrrriNG FORM <br />