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SA NA O A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> 'MADE IN A HOME KITCHEN <br /> Permit p: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Coolies With N'ninuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Any%,[e ,CA 90XM <br /> Ingredients: Enriched flow(llquat flour,niacin.reduced iron,thiamine. <br /> mononitrate,ribollmin and folic acid),butter(milk,salt).chocolme chips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), wnhmts.sngar,eggs, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat.eggs,milk soy,walnuts <br /> Net Wt.3 oz(85.049g) <br /> Note:For the'Issued in County'-Identify the jurisdiction(cityicounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> ase 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 /> (Name of Public Water System or Community Services District: N�lDa <br /> ❑ Private Water Supply", Identify the source (well, spring, surface, etc j)iJ_) <br /> Private Water Suppty: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 requlred 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.w.aov/oroamms/PageslfdbCottoAaFoi>d.aspx <br /> 4 of <br /> EHD 16-27 6/29117 CFO REGIPERMITTING FORM <br />