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SAN <br /> J 0 A Q V I I N Environmental Health Department <br /> J!-4'COUNTY— <br /> Example: <br /> �I O U N TL�Y �1 <br /> Example: <br /> _NL-kDE INA HOME KITCHEN <br /> Permit=: 123.15 <br /> Issued in counri: Count name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 133 Cottage Food Lane <br /> Anywhere.CA 90.1M <br /> Ingredients: Enriched flour(117heat flour.niacin.reduced iron.thiamine. <br /> inononitlate,riboflavin and folic acid).butter(inilk,salt),Chocolate chips <br /> (sugar,chocolate liquor,cocoa batter,butterfat(milk), walnuts.sugar.eggs. <br /> salt,artificial vanilla extract.baking soda. <br /> Contains:Wheat.eggs,mill:,sod•,Nvahiuts <br /> \et 11"t.3 oz.(85.049-) <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 /> >rpublic 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 /> ❑ 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 home with a private water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: <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.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />