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SAN -J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MAD! <br /> H O JIBE �i <br /> � z <br /> -ro#4 e, <br /> Ingredient. ° ❑qtr. <br /> ntourntitrate. 23175 N. Elliott Rd hill, <br /> (sugar.choco Acampo CA 95220 <br /> salt.artificial i., <br /> Permit Mxxx xxxx <br /> Contains:Wheat. Ingredients:Almonds,butter,sugar, <br /> milk chocolate,vanilla and salt. <br /> Net wt.8oz <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 Olp"rivate 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: <br /> Ve(private Water Supply", Identify the source (well, spring, surface, etc.):yn � <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.cdph.ca.gov/programs/Pages/fdbCottage Food.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />