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SAN 10AQUIN <br />JJNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued In county: C'ounly name <br />Chocolate Chip Cookies With Walnut, <br />Sall, Baker <br />123 Cottage Food Cane <br />Anywhere. CA 901' LX <br />Ingredients: Enriched flour M"heal floor, macul. reduced iron. tlumume. <br />mononitrate, riboflavin and folic acid). barter (milk, salt). chocolate drips <br />(sugar. chocolate liquor. cocoa butter. butterfat (milk). ivahmts. sugar, eggs. <br />sal. artificial vanilla extract, baking soda- - <br />Contains: R heal, 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 ❑ 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. sw 10 <br />LJJ Private Water Supply**,Identify the source (well, spring, surface, ettc..) <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 y <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 vide 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 �.cdph.ca.gov/proomms/Pages/fdbCottaiieFood.asp <br />