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SA NA O/( I N Environmental Health Department <br /> —C O U NHQ I Tl�Yt1-1, <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Perudt fl: 12345 <br /> Issued in couny: Couny name <br /> .Chocolate Chip Cookies with Walmrts <br /> sally Biker - <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90X-VC <br /> Ingredients: Enriched limit(wient flour,niacin.reduced itmt thiandne, <br /> moomtitane.riboflavin and folic arid),innrer(milL salt).chocolate chips <br /> (sugar.chocolate licpmr.cocoa looter,brmerfat(hulk). vnalums.sugar.eggs. <br /> salt,artificial vanilla extract,bak-ine soda. <br /> Contains:1111iea,eggs,milk.soy,walnuts <br /> Net 11111.3 oz(05.049g) <br /> Note:For the"Issued in County"-Identiy the jurisdiction(ciryibounty)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: S10CkOfo" M11Atv1C%VPA Wn\01 es <br /> ❑Private Water Supply", Identify the source(well,spring,surface,etc.): <br /> Private Water Supply.Initial Water Quality Results <br /> Check boxes below it 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 Wate 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 f roil <br /> a home with a private water supply-check with local jurisdiction. I <br /> 8. Food Processor Course: Initial if you agree to abide by the following: Sd�l_ <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br /> of completion of the Calltomia 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.m.ewiorooramsftnnlfdbConmeFood.asox <br /> 4 of <br /> EHD 16-27 N29H7 CFO REGIPERMITTING FORM <br />