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SANJOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit 9: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Bnker <br />123 Cottage Food Lane <br />Anywhere, CA 90\-\'X <br />Ingredients: Enriched flmu (Murat flour. nincia. reduced iron, thiamine. <br />mononiante, riboflavin and folic acid), butter (milk, soli), chocolate chips <br />(sutgar, chocolate liquor, cocoa butter. butterfat (null:), walunts, sugar. eegs. <br />salt, artificial tnnilla extract, Viking 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 />® Public Sewer Service <br />❑ Private Septic System <br />In the event of septic system failure or plumbing problem, you am 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: Mountain House CSD Inframark <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 />'(resting 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 ludsdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: <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.cdph.ca.gov/programstPagestfdbCottageFood.asp <br />4 of <br />EHD 16-276129/17 CFO REG/PERMrrTING FORM <br />