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SAN0 A QUIN Environmental Health Department <br /> COUNTY <br /> Example: <br /> 1L�DE IN A HOME KITCHEN <br /> Permit=: 12345 <br /> Issued in count: County name <br /> Chocolate Chip Cookies«`ith Walnuts <br /> Sally Baker <br /> 123 Cotta.,e Food Lane <br /> An3ivhere.CA 90_-=X <br /> Ingredients: Enriched flour(IVheat flour,niacin,reduced iron.thiamine, <br /> mononitrate,ribollal-in and folic acid).butter(mill:,salt),chocolate clips <br /> (mbar.chocolate liquor,cocoa butter.butterfat(nnilk), walnuts.sugar.eons. <br /> salt.artificial vanilla extract.baking soda, y <br /> Contains:Wheat,eggs,mill:,sol-,walnuts <br /> et Wt.3 oz.(85.0.49g) <br /> Note:For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> PIe e 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 /> W Name of Public Water System or Community Services District: C[ d 5+6 <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 /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />