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SA N J O A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HO\IE IQTCHEN <br /> Permit#: .12345 <br /> Issued In county: Counh,name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Cane <br /> Anym1here,CA 90=X <br /> Ingredients: Enriched flow(Wheat flow,oinchr.reduced iron,thiantine. <br /> mononitrate,ribollmin and folic acid).butter(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk). unh nts,sugar,eggs. <br /> salt.artificial smnilla exhacy baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> \et Wt.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 /> Pease check what type of treatment is used to dispose of waste <br /> XPublic 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: G I f y At W -1 <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 Departmentopleaseppoyide proof <br /> of completion of the California Food Handler course in lieu of the California Department of?ublic-Heafth` <br /> (CDPH)food processor course. <br /> For more information see CDPH website www.cdph.ca.gov/proomms/Pages/fdbcotteneFood.aspx <br /> 4of5 <br /> EHD 16-27 6120/17 CFO REGIPERMITTING FORM /' <br />