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S A N J O A f1 U IN <br /> Environmental Health Department <br /> — COU IN TY <br /> Example: <br /> MADE IN A IIOME KITCHEN <br /> Permit R: 12345 <br /> Issued in county: Coutuy name <br /> Chocolate Chip Coolies With\Valuuts <br /> Sally Baker <br /> 123 Cottage Food Lute <br /> Anywhere,CA 90kkfi <br /> Ingredients: Enriched Dour(\\heat Dour,niacin,reduced iron,thiamine, <br /> mononitrate,riboflavin and folic acid),butter(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(ir lk), walnuts.sugar,eggs, <br /> salt,artificial vanilla extract,bakin=soda. <br /> Contains:Wheat,eggs,mill:,soy,walnuts <br /> Net\\'L 3 oz.(85.0498) <br /> Note:For the'Issued in County'-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> lease 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 /> )4-bl1 r <br /> ame of Public Water System or Community Services District: ilft � r<_- f <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 jurisdictiori. <br /> S. 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.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />