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SAN 10AQUIN <br />Environmental Health Department <br />Example: <br />XUDE L\ A HOME EaTCHE\ <br />Permit': 12345 <br />Issued iQ minty. Counrt' name <br />Chocolate Chip Cookies With Wahmts <br />Sxty Baker <br />123 Cottage Fend Lane <br />5JIN11 here CA 901 -C -1c <br />Ingredients: Fmtched flour (111cat noun. uiacm teduced non. thiainu c. <br />monmutmte. iibolLi%w and folic acid). btmer nnilL ,alt). chocohre chips <br />isi=. chocolate liquor. nxva butter. britt{at (n)M). w;duuts, sugn. ergs. <br />salt Murieial tanilla airaeL baling sesta. <br />Contains: 'Wheat. eggs, hunt:, soy. walnuts <br />Net R"L 3 oz (55.0499) <br />(Vote: 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 <br />❑ 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: i ` <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 (yeariy'): <br />❑ Nitrite Test (every 3 years`): <br />—Additional infomration may be required if food is prepared from a home with a ptivme Mter supply —check with local jurisdiction. <br />S. 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 infuriation see CDPH website wvrsa.cdolhca.acv(oraommslPzaeslfdbCotraaeFoetdasox <br />4 of <br />EHD 16-276MM7 CFO REGIPERMtrrING FORM <br />