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SANJOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME IUTCHEN <br />Permit #; .12345 <br />Issued in eoantyt County name <br />Chocolate Clip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Looe <br />Anywhere, CA 90:CM <br />Ingredients: Enriched flair (Wheat flour, (oaths, reduced iron, thiasuine, <br />mmmnitrate, riboflavin mid folic acid), butter (milk, sa1Q; chocolate clips <br />(sugar, chocolate lignor, cocoa Hitter, butterfat (uulk), walnuts, sugar, eggs, <br />salt, mti5cial vatulla extract, baking soda. - <br />Contains:+Wheat, eggs, milk, sty; walnuts <br />Net \YL 3 oz (85.049g) <br />jN f For the "Issued In County"- Identify the jurisdiction Coity/county) where you we obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment Is used to dispose of waste <br />0 Public Sewer Service ❑ Private Septic System <br />In the event of septic system failures 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: C01 !q i elu <br />❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): <br />Private Wafer Supply. Initial We ter Qua lityResults . <br />Check boxes below 9 initial water testing has been completed. <br />All testing must be done at a Stale Certified Laboratory. Either attach lab results or provide name of lab, date & <br />results in space provided next to type of test. <br />*(Testlng 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 />*'Addkloral Information may be required If food Is prepared from a Forma with a private water supply -check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: 0 <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 infoonatlon see CDPH websde www.cdch.co.covtorocrams#Paces/fdbCottaceFood.asox <br />4oF5 <br />EHO 16-27 6/29117 CFO REGIPERMITTING FORM <br />