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SA N J 0 A 0'.0 I N Environmental Health Department <br /> Example: <br /> MADE INA HOTtE 1QTCHEN <br /> Permit#: 12115 <br /> Issued In county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Balser <br /> 123 Cottage Food late <br /> :m'dere.C 90a'l' <br /> Ingredients: Enriched flour M-heat flat,niacin,reduced iron thiamine. <br /> mononitrate.riboflarim and folic and).timer(mill',salt)_ciocolare claps <br /> (su®r,chocolate liquor.cocoa boner,butterfat(milk). walnuts,sugar,egg, <br /> salt,artificial sanilla extract,baking soda. <br /> Contaias:R'bear,eggs,milk,soy,walnuts <br /> Net t\t.3 oz(85.049g) <br /> Note:For the'Issued in County'-Identify tha junsdfchon(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: G" p f IlaC y <br /> ❑ Private Water Supply", Identify the source(well, spring, surface,etc.): I <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 inforrinatron may be required if food is prepared from a hone 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, pleas 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 websde www cd h ca aov/t of ams/PaaestkibCottaaeFood ox <br /> EHD 16-27629/17 CFO REG/PERMITTING FORM <br />