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SAN JOAQUIN <br />— <br />—COUNTY- -- <br />Environmental Health Department <br />Example,• <br />i4IADE W A HOME KITCHEN <br />Permit 4: 12345 <br />Issued In county•: County name <br />Chocolate Chip Cookies Willi Walonts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90a.\ <br />Ingredients: Enriched flour (Wheat flour, tliacut, reduced iton, thimnine. <br />mononimite, rilwflavin and folic acid). batter (su ilk. salt). chocolate chips <br />(sugar. chocolate liquor. cocoa hotter. butterfat (milk). ominurs. sugar, eggs. <br />sa1L anificial vanilla extract. baking soda. <br />Contains: Wheat, eggs, milk, say, walnuts <br />Net Wt. 3 az (85.049g) <br />Note: For the 'Issued in County°- Identify the jurisdktion (city/counly) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />X 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 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 />❑ 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 />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 welisite www.cdoh.ca.aovloronrams/Panes/fdbCottaceFood.aspx <br />4 of <br />