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SAN .J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit q: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Coolies Widi Walums <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.VEX <br /> Ingredients: Enriched gay(NI-heat flour.niacin.reduced iron.thiamine. <br /> mwmonihnte.riboflavin mid folic acid),butter(urilk,salt),chocolate drips <br /> (sugar.chocolate liquor.cocoa butter.butterfat(milk). walnuts.sugar.eggs. <br /> Wt.artificial v villa extract,baking soda. <br /> Contains:%1k heat,eggs,milk,sov,walnuts <br /> Net Wt.3 oz(85.049g) <br /> Note:For the"Issued in Counly"-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 21 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: 11 <br /> 0 Private Water Supply* , Identify the source(well, spring, surface, etc.): <br /> Private Water Supply:Initial Water Quality Results V <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) SPx2,(Vw a Ld <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.cdpbza.gov/programs/PageslfdbCottageFood.aspx <br /> 4 of <br /> EHD 16-276/29117 CFO REGIPERMITTING FORM <br />