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SANJ O A Q U I N Environmental Health Department <br /> Example: <br /> NUDE KN A HOME KITCHEN <br /> Permit';: 12345 <br /> Issued in cemaq: Counts name <br /> Chocolate Clip C'onLie,With R;1113111, <br /> Salle Rakei <br /> IouaLe Elm]Lane <br /> Ame here-l A vuXXX <br /> Ingredients: Ftuiched flow(NYheat floun macro.reduced unit.thinnune. <br /> nunwuihete.Iibollaci11 mal lidic acid),butter milk,.ah),chocolate chip, <br /> chncolaW hquot.cocoa bnner.bunerfin undk). u.11111r1,.gwffl.eees. <br /> .:dt.atnlicml c,ntifla rwaci bakwn .s.od . <br /> Contains:%%heal.errs.mUL soy.walnuts <br /> Net AN t.3 oz.(85.049g) <br /> Note:For the"Issued in County"-Identity the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Pte se check what type of treatment is used to dispose of w to <br /> Sewer-Seruise to Private Septic System <br /> tQ I`nlLI <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 /> P se Identify the water source to be used in Cottage Food Facility(check one box) <br /> Iptj�,6( NName of Public Water System or Community Services District: CIS, A+ �G�4 ^ <br /> [rrrivate Water Supply", Identify the source(well, spring, surface, etc.): � 1� (✓i"}z UA Guih� <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 home with a private water supply-check with local jurisdiction.. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: W <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.cdoh.ea.aovipMrams7PaoestfdbCotraoeFood.asox <br /> EHD 1627 6/29/17 CFO REG/PERMFTING FORM <br />