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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued in county: County name <br />Chocolate ('Lip Cookias !Gill Wal nns <br />Sulk Raker <br />123 ('ouaee foml Lane <br />Anq\Lele. CA 90SX.0 <br />Ingredients: 6nichz(t Flmu t\\'Imat itmv. utaciu. rzduecvl iron. thianuue. <br />uronouitntz. rilmtlaviu and folic acid). Nam inulk salt). chocolate chip, <br />tnruar. chocolate liquor. cocoa boner. butterfat uuilky scalnuts. 10Ua1. e_e., <br />kali. auificial sanilla exuact.!raking soda. <br />Contains: R heal, eggs, milk, soy, walnuts <br />'set NA -1. 3 oz. (85.0498) <br />Note: For the "Issued in County" - Identify the jurisdiction (city/county) where you are obtaining approval. <br />6. Disaosal of Waste: <br />Ple se 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: k7 <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc.): t <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.edoh.ca.aov/proarams/Panes/fdbCottaaeFood.asox <br />, oIG <br />EHD 16-27 6/29117 CFO REG/PERMITTING FORM <br />