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SAN_JOAQUIN <br />COUNTY— <br />Environmental <br />OUNTY <br />Environmental Health Department <br />Example: <br />\EIDE INA MAIL KITCHEN <br />Permit =: 12345 <br />Lwed in comrc: Comrty name <br />Chocolate Chip Cookie. uLh Walnuts <br />Sally Bakes <br />123 Cottaee Food Lane <br />Amnvhere. CA 90.\'Kk <br />Ingredients: Enriched flour (Wheat flour. niacin, reduced iron, thhuuiue, <br />mononitrate, riboflavin and fohc acid), butter (milk, salt), chocolate chips <br />(sugar. chocolate liquor, cocoa butter, brmerfat (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 />Pie a check what type of treatment is used to dispose of waste <br />ublic Sewer Service El 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: Ca C cf�c� <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: <br />SJ l4/ <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 (CDPH) <br />food processor course. <br />For more information see CDPH website www.cdoh.ca.aovioroorams/Pages/fdbCottageFood.asox <br />4 of 5 <br />