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SANJ O A Q U I N Environmental Health Department <br /> —C C. TY— <br /> Example: <br /> NLADE IN a HOME KITCHEN <br /> Permit k: 12345 <br /> Issued in county: County some <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food wane <br /> Anvlvhere.CA 90N-%X <br /> Ingredients: Enriched flour(Wheat flow,niacin.reduced iron.thiamine. <br /> monouinate,riboflavin acrd folic acid).batter(milk salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(milk). walnuts.sugar.eggs. <br /> salt artificial vanilla extract,baking soda. <br /> Contains:RLeat,eggs,milk,soy,walums; <br /> Net Wt.3 oz(W.049g) <br /> te:For the'Issued in County"-Identify the junsdiction(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: <br /> EZ 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 /> O-Bacteriological Test(quarterly`): <br /> Nitrate Test(yearly-): <br /> Ed/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: �515 <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.cdohmaaov/omarams/PageslfdbCottaaeFood.asox <br /> 4 of 5 <br /> EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />