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Environmental Health DepartmentSHn10H1uI <br /> COUNTYExample: <br /> MADE IN A HOME KITCHEN <br /> Permit N: 12345 <br /> Issued to county: County rune <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Luce <br /> Anywhere.CA 90XXX <br /> Ingredients: Enriched flour(Wheat flour.niacin,reduced iron,thiamine, <br /> mononitrate,riboflavin and folic acid).butter(milk,salt),chocolate chips <br /> (sugar.chocolate liquor.cocoa butte.butterfat(milk), walnuts.sugar.eggs. <br /> salt,artificial vanilla extract.baling soda. <br /> Contains:Rbeat,eggs,mill:,soy,walnuts <br /> -Net Wt.3 oz.(85.049g) <br /> Note:For the'Issued in County"-Identify the jurisdiction(city/counly)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> [4 Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to ratify 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 /> P Name of Public Water System or Community Services District: C t T-""( o(-- Lq 1 Nk-c�P <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 Fame with a private water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: T, l�J✓I <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.edph.cagovipruarams/PanesffdbGoftageFood.aspx <br /> 4 of <br /> EHD 16-27 6129/17 CFO REG/PERMITTING FORM <br />