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—JH N.J O HQ I N <br /> Environmental Health Department <br /> COUNTY— Example: <br /> MADE IN A HOME KITCHEN <br /> Permit it: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90X.1-X <br /> Ingredients: Enriched flmr(Mien flour,maths,reduced iron,duanune, <br /> nsonositmte,riboflavin and folic acid),barter(hulk.salt),chocolate chips <br /> (suear,chocolate liquor,cocoa butter,butterfat(nufl:), amhnus,sugar,eggs. <br /> salt,nnificial mulls extract,baking soda. <br /> Contains:Whent,eggs,milk,soy,walnuts <br /> Net Wt.3 oz(85.0498) <br /> N.QIL 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 /> 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 /> Pese Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: I\rY1 R 6_� <br /> El 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 tab results or provide name of lab,date& <br /> results in space provided next to type of test. <br /> '(Tesfing 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 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, please rovlde 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.cOph.co.goyloroaram$/Pa0eS/fdbCottaneFood.asox <br /> 4 of <br /> EHD 16-27 6/29117 CFO REGIPERMITTING FORM <br />