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SA N sJ O A Q I I N Environmental Health Department <br /> _IC OUNTY--- - <br /> Example: <br /> Viylna del Sole <br /> FARMSTEAD <br /> LAVENDER VINEGAR <br /> Made In A Home Kitchen <br /> 2668 trafton Way, Stockton CA 95204 <br /> Permit# Issued in San Joaquin County <br /> Ingredients: Balsamic Vinegar, Lavender Extract <br /> Net Weight 12 oz. (340.194g) <br /> ! <br /> Contalm:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3o (85.049g) <br /> Note:For the"Issued in County"-Identify thejurisdiction(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 /> VPublic 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 /> [Fame of Public Water System or Community Services District: 0.a I4rhl <br /> ❑ Private Water Supply—, Identify the source (well, spring, surface,etc.): ! / <br /> Private Water Supply:Initial Water Quality Results <br /> r 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 8 <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: Yn,� <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 moreiinformation see CDPH website www.cdph.ca.aov/proarams/Panes/fdbCoftageFood.asDx <br /> 4 of <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />