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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A HOME IQTCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baler <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90t'LX <br /> Ingredients: Enriched flour(Wheat flour,niacin,reduced iron.thiantite. <br /> mononitrate,riboflavin mid folic acid),butter(mi k,salt),chocolate chips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walnuts.sugar,eggs, <br /> salt,artificial vanilla Winer,baling soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net NVt.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 /> Plea a check what type of treatment is used to dispose of waste <br /> Plea <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) <br /> Name of Public Water System or Community Services District: �Ibww ujoz I,f Sky u t'U <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 homevdth a private water supply—chock with local jurisdiction. r <br /> 8. Food Processor Course: Initial if you agree to abide by the following: lr <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.ca,eovlprogramslPageslfdbCottaeeFood.aspx <br /> 4 of <br /> EHD 16-27 6129117 CFO REGIPERMITTING FORM <br />