Laserfiche WebLink
SA N x10 A Q U IN Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit 8: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies with Walnuts <br /> Sally Bake <br /> 123 Cottage Food Lane <br /> Anymtrere,CA 90\-%-C <br /> Ingrnlients: Enriched flour(Mq I Born,niacin,reduced irmt.thiamine. <br /> nnononitraia,ribollam and folic acid).butte(nulk,sal),chocolate chips <br /> (sugar.chocolate liquor,cocoa butte,butterfat(milk,). ealnuts,sugar.eggs, <br /> salt,artificial vanilla extract.baking soda, <br /> Contains:1\Teat,eggs,milk,soy,walnuts <br /> Net\Yt.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 /> Please 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: MHCSD <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 pdvate water supply-check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: PJ <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 websfte www.cdph.o.nov/proarams/PaAes/fdbC*ttageFood.aspx <br /> 4 of <br /> EMD 1627 6/29117 CFO REGIPERMITTING FORM <br />