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SANJ O A Q U IN Environmental Health Department <br /> COUNTY <br /> Example: <br /> ANDE IN A HOME KITCHEN <br /> Penni(p: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Biker <br /> 123 Collage Food Lane <br /> Anywhere,CA 90N'C <br /> Ingredients: Ermched flour(Wheat flour,niacin,reduced iron,thiamine, <br /> mononitrate,riboflnrin and folic acid).butter(milk,salt),chocolate clips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walnuts.sugar,eggs. <br /> salt,artificial vanilla extract,bakime soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 am(85.049g) <br /> Note:For the'Issued in County"-identify 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 /> ❑ 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: S�Q <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 /> Private Water Supply", Identify the source (well, spring, surface, etc.): Vv v'i <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 /> ❑ 'trate Test(yearly`): <br /> VeitriteTest(every 3years"): gqdq r7gw, ,pyo/; 2,D— y7(o_ p7( <br /> Additional information may be required If food is prepared from a home with a private water supply—check with local jurisdiction. <br /> B. Food Processor Course: Initial if you agree to abide by the following: Kel <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 webske www.cdph.ca.ciovlr)roomms/Pacies/fdbCottageFood.aspx <br /> 4 of <br /> EHD 1627 8/29117 CFO REG/PERMITTING FORM <br />