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SANJ O A Q U I N Environmental Health Department <br /> Example: <br /> _NUDE IN A HOME KITCHEN <br /> Permit#: 12344 <br /> Issued in county: County name <br /> Chocolate Chip Cookies NF9th Walnuts <br /> Sally Baker <br /> 133 Cottage Food Lane <br /> Atmvhcre.CA 905.1X1 <br /> Ingredients: Enriched flout:(Micat flour.tuacin.reduced iron.ditanune. <br /> mououitmte.riboflavin and folic acid).butter orulk.salt),chocolate claps <br /> (sugar,chocolate liquor.cocoa butter.butterfat(uulk). walnuts.sugar,eggs. <br /> salt artificial vanilla extract.baking soda. <br /> Contains:Wheat.eggs,milk.soy,walnuts <br /> Net Wt.3 oz.(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 /> dPublic 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 /> ,P�eae Identify the water source to be used in Cottage Food Facility(check one box) <br /> r Name of Public Water System or Community Services District: (tea\ W(JAP_r <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: �S <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.r .oov/orograms/Pages/fdbCottacieFood.asox <br /> 4 of <br /> EHD 16-27 6/29/17 CFO REG/PERMFTING FORM <br />