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SANJ O A U U I N Environmental Health Department <br />Example: <br />MADE W A HOME KITCHEN <br />Permit a: 123$ <br />Issued In coualc: (ounty name <br />(hocolme ('lup ( o Ales if III, \P91111115 <br />Sall, Baker <br />Ia conxve F,x,d Laic <br />Ami%here CA 90Vce <br />Ingrnllrnls: EurichsKl anal I\111cit nein. wacnl. r<Juccd lino; Ihlamne. <br />mououittate, dboffivin and fubc acid). butler Inulk. Sall). chocolate cldjh <br />fsueal, chocolate hquor, es,coa bu0er, buncdal milk), w'sluuu. Sugar. egg,, <br />salt. anticinl %milia extinct, baking Saki <br />Contains: Wheat, eggs, mink, wy, nalnuts <br />Net \\'t. 3 oz. (85.047%) <br />Note' For the *Issued in County-- Identity the jurisdiction (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 />1� Public Sewer Service <br />❑ Private Septic System <br />In the event of septic system Failure or plumbing problem, you are required to notify San Joaquin County Environmental Health Departrrcnt <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: C iN 0Y ?_I P 0\'l <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 maybe required tf food is prepared from a home with a private water supply —check with local jursdkbon. <br />6. Food Processor Course: Initial if you agree to abide by the following: >4�__ <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.ca.amiprooramslPanes/fdbCottanoFood.asox <br />i of <br />EHO 16-27 6/29V17 CFO REGIPERMITTING FORM <br />