Laserfiche WebLink
SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A HO-NIE KITC IIEN <br /> Permll#: 123+5 <br /> Issued in county: C'ounh name <br /> Chocolate Chip Cookies With Walnuts <br /> Salle Baker <br /> 12;Clottage Food Lane <br /> Anywhere,CA 90XXX <br /> Ingredients: Enriched flour(Mreat flour.niacin.reduced iron,thiamine. <br /> mononitrate.n otlavin and folic acid).butter(hulk,salt),chocolate chips <br /> (sugar.chocolate liquor.cocoa butter,butterfat(hulk). Nvahmts.suear.eggs. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz.(85.1149-0 <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 /> ZPublic 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: ` O <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.edph.ca.aov/programs/Pastes/fdbCottaneFood.aspx <br /> int=; <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />