Laserfiche WebLink
SA N 'J 0 A Q U IN Environmental Health Department <br /> —COU NTY— <br /> Example: <br /> MADE IN A HOME KITCHEN' <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies A'itli Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> AinivItere,CA 901 \ <br /> Ingredients: Enriched floor(Vllteat flour,tuacui,reduced iron.tluamine. <br /> mononitrate.riboflavin and folic acid).butter(uulk.salt).chocolate claps <br /> (swear.chocolate liquor.cocoa butter,butterfat(null:). waborts,sugar,eggs. <br /> salt.artificial N anilla extract,baking soda. <br /> Contains:Wheat,eggs,mill:,soy,ssainuts <br /> Net«'t.3 oz.(85.049g) <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 /> 9 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 /> M Name of Public Water System or Community Services District: Byron-Bethany Irrigation DlStrict(BBID) <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: LG <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.cdoh.ca.govlnroarams/Pa-QGWMbCottageFood.asax <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REGIPERMITTING FORM <br />