Laserfiche WebLink
'S AJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit M 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Aay�vhere.CA 90)0"\ <br /> Ingredients: Enriched flour(Micat flour.niacin,redt►ced iron.thiamine. <br /> mononitrate,riboflavin and folic acid).butter(wilk salt),chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,butterfat(milk), wahmts,sugar.eggs. <br /> salt,mtificial vanilla extract,baking soda. <br /> Contains:NNireat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz.(85.049g) <br /> Note:For the Issued in County"-Identify the jurisdiction(city/courtly)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 /> A Name of Public Water System or Community Services District: Q 'au <br /> CA '�} = <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, etc.). �� <br /> Private Waiver Supply:Initial Water Quality Results <br /> Check boxes belay:if initial water testing has been completed. <br /> All testing must be dome 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(quaderiy*)- <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 websiieww—.c+eh ca.novlprcnramcfPacieVfdbCoOttaneF^M.2y4�}�S. <br /> 4of5 <br /> EHD 16-27 6129/17 CFO REG(PERMITTING FORM <br />