Laserfiche WebLink
SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A I-10ME 10TCIIE\ <br /> Permit#: 12345 <br /> Issued in countY: CoWItP name <br /> Chocolate Chip Cookies With W1111uts <br /> Salle Baker <br /> 123 Cottage Food Lane <br /> 1nymhere.CA 90tt\ <br /> Ingredients: Enriched flour(Wheat flour,niacin.reduced iron.thiamine, <br /> mononitrate,ribotlavin and folic acid).butter(milk,salt).chocolate chips <br /> (su_ar.chocolate liquor,cocoa butter,butterfat(milk), walnuts,sugar.e,_L.s. <br /> salt,artificial vatvlla extract.bakine soda. <br /> Contains:Allteat,eggs,rill:,soy,A a6ntts <br /> Net Wt.3 oz.(8-5.1149-) <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 /> Z 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 /> ❑'dame of Public Water System or Community Services District: S�OC �-� a� r <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 <br /> (CDPH) food processor course. <br /> For more information see CDPH website www.cdpli.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />