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SAN <-J O A Q U I N Environmental Health Departmerit <br /> C0UI\TY <br /> Example: <br /> NI_-1DE IN A HOJIE KITCHEN <br /> Permit#: 12345 <br /> Issued in count: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 1-';Cottage Food Lane <br /> Ain-where.CA 90X-1'X <br /> Ingredients: Enriched flour(X1lteat flour.niacin,reduced iron.thiuuine, <br /> ntononin<ate,riboflavin and folic acid).butter(milk.salt).chocolate chips <br /> (sugar.chocolate liquor.cocoa butter,butterfat(milk), walnuts,sugar,eggs. <br /> salt,artificial vanilla extract.baking soda. <br /> Contains:Wheat,eggs,milk,soy.walnuts <br /> \et'%N"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 /> Pie se check what type of treatment is used to dispose of waste <br /> Pie <br /> 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)C V4 <br /> n <br /> [JName of Public Water System or Community Services District: c 6 ,, `e 1-tv <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 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.cdt)h.ca.gov/programs]Pages/fdbCottageFood.asDx <br /> dof5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />