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SAN JOAQUIN <br />C(71I,',:TY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN' <br />Permit #: 12345 <br />Issued in rouniv: County name <br />Chocolate Chip Cookies \Pith Walunts <br />Salle Baker <br />123 Cottage Food Lane <br />Arnwhere. CA 90X1'\ <br />Ingredients: Enriched flow (Alrew flora, viacn reduced iron. thiamine. <br />mououitinte. riboflavin and Colic acid). batter (milL salt). chocolate chips <br />(sugar. chocolate liquor. cocoa butter. butterfat (oink). wahmts, sugar. eggs- <br />silt. <br />ggssalt. artificial vanilla extinct. baking soda. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net Rt. 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 />❑ Public Sewer Service <br />�rivate 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: <br />�rivate 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: �w <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />of completion of the Califomia 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-ra.gov/Programs/Pages/fdbCottaueFood.asox <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />