5. All applications materials are available on our website at http

COTTAGE

FOOD OPERATION APPLICATION

GUIDE

SISKIYOU

COUNTY

ENVIRONMENTAL HEALTH DIVISION

806 South Main Street, Yreka CA

96097

Phone:

(530)

841-2100 / Fax:

(530)

841-4076

COTTAGE

FOOD OPERATION APPLICATION

REQUIREMENTS

ln order to assure

your

application is

processed

expeditiously, we ask for

your

cooperation

the following items:

Self Certification Checklist.

The self certification

checklist must be

properly

filled

out

and signed by all applicant(s) and

property

owner(s).

Water and Sewer Clearance. All

applications submitted for operations

that are not on

a municipalwater

and sewer system require

a signed verification

statement from the

Environmental

Health Division that

sewer capabilities and

the

water

supply for the

proposed

cottage

food

operation are sufficient

meet

State and County requirements.

the CFO will be served by

private

water

system, a CFO Water System

permit

will be

necessary

part

of the Water and Sewer

Clearance.

The

"Cal

Code Food

Facility/Cottage Food

Operation

Water

System

Permit Application" must

be submitted with

the self-certification checklist.

Business License. lssuance of a business license from the County

Treasurer-Tax

Collector or

the local City Authority

is required

prior

to operation.

Business licenses are to

renewed annually.

Additional

lnformation.

As the applicant,

you

may be asked to

provide

more detailed

information on the

project

part

of the

application requirements.

You are

responsible for

providing

sufficient

information to the County to allow

proper

review of

your

application.

you

are unable

or unwilling to

supply

adequate

information,

your

application will, of

necessity, be denied.

5. All applications

materials are

available on

our website at

http://www.co.siskivou,ca.us/page/[email protected]

TYPED or PRINTED

NEATLY in black

ink

Please

note that the staff

has been

instructed

NOT TO ACCEPT

incomplete applications.

you

are

unable to

provide

requested

information,

please

speak

with staff

to determine a

proper

course

action.

Acceptance

your

application

the

Commu

not

guarantee

your

application

wil! be approved

nity

Development

Depa

rtme

COTTAGE FOOD OPERATION

FREQUENTLY ASKED

QUESTIONS

WHAT IS A COTTAGE FOOD

OPERATION

(CFO)?

CFO

an enterprise

at a

private

home where low-risk food

products

are

prepared

packaged

for

public

consumption.

WHAT

IS MEANT BY

"PRIVATE

HOME?"

"Private

home" means a dwelling, including an apartment or other leased space,

where

individuals reside.

WHAT ZONING DISTRICTS PERMIT CFOs?

A CFO may be established in any dwelling

regardless

of zoning

provided

the CFO complies

with all applicable state laws.

WHAT ARE

THE DIFFERENT TYPES OF CFOS?

(1) "Class

A" CFOs are only allowed to engage in

"direct

sale" of cottage

food

products.

(2) "Class

B" CFOs may engage in both

"direct

sale" and

"indirect

sale" of cottage food

products.

WHAT IS MEANT

"DIRECT

SALE" OF COTTAGE FOOD?

"Direct

sale" means

a transaction between a CFO operator

and a consumer, where the

consumer

purchases

the cottage food

product

directly from

the CFO. Direct sales include,

but

are not limited to, transactions

holiday

bazaars or

other temporary events, such

as bake

sales or food

swaps, transactions

farm

stands, certified farmers'

markets, or

through

community

supported agriculture

subscriptions, and transactions

occurring in

person

the

cFo.

WHAT IS MEANT BY

"INDIRECT

SALE" OF COTTAGE

FOOD?

"lndirect

sale" means an interaction

between a CFO, a third-party retailer,

and a consumer,

where

the consumer

purchases

cottage food

products

made

by the CFO from a third-party

retailer

that holds a valid

permit

issued by

the local health department in

their

jurisdiction.

lndirect

sales include, but

are not limited to, sales made

to retail shops

or to retail food facilities

where food

may be immediately

consumed

on the

premises.

CAN A CFO

SELL

COTTAGE

FOOD

OUTSIDE THE

COUNTY

OF RESIDENCE?

CFOs

can only

sell cottage

food

outside the

county

of residence

when

the local

health

department

of the

outside

county

allows it.

WHAT TYPES

COTTAGE FOOD CAN

A CFO PREPARE?

Only foods that

are defined

"non-potentially

hazardous"

by the State are

approved for

preparation

by CFOs. These are foods that do not require refrigeration to keep them safe from

bacterial

growth

that

could

make

people

sick.

The

California

Department

Public Health

maintains a list of these approved foods on their website. The list currently includes:

(1)

Baked

goods

without cream, custard, or meat fillings,

such

as breads, biscuits,

churros,

cookies,

pastries,

and tortillas;

(2)

Candy, such as brittle and totfee:

(3)

Chocolate-covered nonperishable

foods,

such as nuts and dried

fruit;

(4)

Dried fruitl

(5)

Dried

pasta;

(6)

Dry baking mixes;

(7)

Fruit

pies,

fruit

empanadas,

and fruit

tamales;

(8)

Granola, cereals. and trailmixes:

(9)

Herb blends and dried mole

paste;

(10)

Honey

and sweet sorghum

syrup;

Jams,

jellies,

preserves,

and

fruit

butter that comply with the standard described in Part

'150

of Title 21 ofthe Code of Federal Regulations;

(12)

Nut mixes and nut butters;

('13)

Popcorn;

(14)

Vinegar and mustard;

(15)

Roasted coffee and dried tea; and

(16)

Waffle cones and

pizelles;

(17)

Cotton candy;

('18)

Candied apples;

(19)

Confections such as salted caramel, fudge, marshmallow

bars, chocolate covered

marshmallow, nuts, and hard candy, or any combination

thereof;

(20)

Buttercream frosting, buttercream icing, buttercream fondant,

and cum

paste

that do

not

contain eggs, cream, or cream cheese;

(21)

Dried or Dehydrated vegetables;

(22)

Dried vegetarian-based soup mixes;

(23)

Vegetable

and

potato

chips;

(24)

Ground chocolate;

(25)

Seasoning salt;

(26)

Flat icing.

(a)

cottage

food

preparation, packaging,

or handling may occur in the home kitchen

concurrent with any

other domestic activities, such as family meal

preparation,

dishwashing, clothes washing or ironing, kitchen cleaning, or

guest

entertainment.

(b)

No infants, small

children, or

pets

may be in the home kitchen during the

preparation, packaging,

or handling of any cottage food

products.

(c)

Kitchen equipment

and utensils used to

produce

cottage food

products

shall be

clean and maintained in a

good

state of

repair.

(d)

AII food contact surfaces, equipment, and utensils

used

for

the

preparation,

packaging,

handling

of any cottage food

products

shall be washed, rinsed, and

sanitized before each use

(e)

All food

preparation

and food and equipment storage areas shall be maintained free

of rodents and insects.

Smoking shall be

prohibited

in the

portion

private

home used for the

preparation,

packaging,

storage, or handling of cottage food

products

and related

ingredients or equipment,

or both,

while

cottage food

products

are being

prepared,

packaged,

stored, or handled.

(2)

Person with contagious disease must refrain from work.

(3)

Hands and exposed

portions

of arms of

food workers

must be kept clean and washed

before any food

preparation

packaging.

(4)

Water

used

in food

preparation

activities must be

"potable"

as defined by Health and

Safety Code

113869. This includes:

(a)

Wash, rinsing, and sanitizing

equipment used

in food

preparation;

(b)

Washing and sanitizing hands and arms; and

(c)

Water used in ingredients of food

(5)

All

persons

who

prepare

package

cottage food

products

must complete a food

processor

course instructed by the California Department of Public Health within three

(3)

months of becoming

permitted.

(6)

No employee shall commit any act that may cause the contamination

or adulteration of

food, food-contact surfaces, or utensils.

(7)

Gloves shall be worn when contacting food and

food-contact

surfaces if the cottage food

operator

has

any cuts, sores,

rashes,

artificial

nails, nail

polish,

rings

(other

than a

plain

ring,

such as a

wedding

band), uncleanable orthopedic support devices, or fingernails that

are not clean, smooth, or

neatly

trimmed.

(Please

refer

Health

& Safety Code Section

'113973

for

the

full

text of the

law.

WHAT

ARE THE CFO'S OPERATIONAL REQUIREMENTS?

(1)

Prior to

permit

issuance,

all CFOS must submit a self-certification checklist to verify the

following

criteria are met:

lf the CFO

is served by a

public

water system, the water has already been tested

by the local

water

agency

and determined to be

potable.

lf the CFO is not served

by a

public

water system,

the system will require a CFO

Water System Permit from the Community Development

Department as

part

the Water and Sewer Clearance. Please contact the

Environmental

Health Division regarding a CFO

Water

System

Permit if necessary.

HOW

OFTEN

ARE CFOs INSPECTED?

"Class

A" CFO food

preparation

and storage areas are only

inspected when a consumer

complaint

is being investigated.

CFOs may not have

gross

annual sales that exceed

$35,000

in 2013,

$45,000

in 2014,

and

$50,000

in 2015 and

each

year

thereafter.

ARE

CFOs ALLOWED TO HAVE EMPLOYEES?

addition

to the cottage food operator, one full{ime equivalent cottage food employee is

permitted.

Cottage

food

employees

do not include immediate family members or members of

the same

household

as the

cottage food operator.

WHAT TYPE OF LABELING

IS REQUIRED

COTTAGE FOOD PRODUCTS?

All cottage food

products

must be

labeled

consistent

with

the

Federal Food, Drug, and

Cosmetic Act

(21

U.S.C. Sec. 343 et seq.).

Additionally, to the extent

permitted

by federal law,

the label shall include, but

is not limited to,

all of the

following:

(1)

The

words

"Made

in a Home Kitchen" in 12-point type on the cottage

food

product's

primary

display

panel.

(2)

The name commonly

used for the food

product

or an adequately

descriptive name.

(8)

All food shall be manufactured,

produced, prepared,

compounded,

packed,

stored,

transported,

kept for sale, and served so as to be

pure

and

free from

adulteration

and

spoilage; shall have been obtained

from

approved sources;

shall be

protected

from dirt,

vermin, unnecessary

handling, droplet contamination, overhead leakage, or other

environmental sources of contamination; shall otherwise

be fully fit for human

consumption; and shall

conform to the applicable

provisions

of the Sherman Food,

Drug,

and Cosmetic Law.

For a more complele understanding

of the regulations by which CFOs must operate,

please

familiarize

yourself

with Health and Safety Code Sections 109947

1 1 0050, 1 10460,

1 1955,

113758, 113789, 113851,

113953.3, 1'13967, 1'13973, 1'13980, 114021

114023, 114088,

14365, 114365.2., 114365.5.,

114365.6., 1'14390, 114405, 114409, 114259.5, 114285,

114286, 114405, 114407,

114409, 114411,

and

114413. This information is located at:

htto://www.leqinfo.ca.oovlcalaw.

html.

HOW DO I KNOW

IF MY WATER IS POTABLE?

"Class

B" CFO

food

preparation

and storage areas are inspected

prior

permit

issuance

(permits

are

issued

on an annual

basis) and when a consumer complaint is being investigated.

ARE

THERE INCOME LIMITS ASSOCIATED WITH CFOs?

(3)

(4J

The name,

city, and zip code of the CFO which

produced

the cottage food

product.

The

permit

number

of the CFO that

produced

the cottage food

product

and, the name of

the county

that

issued

the

permit (Siskiyou

County).

(5)

The ingredients

of the cottage lood

product,

in descending

order of

predominance

weight, if

the

product

contains two or more ingredients.

(6)

The netweightofthe

product

listed in both English

(ounces/punds)

and metric

(grams)

unils

(7)

Major

allergens such as milk, eggs, fish, shellfish, tree nuts, wheat,

peanuts,

and

soybeans listed in

plain

English

either in the ingredients list or in a

separate statement.

All labels must

legible

in English and must not smear. All labels,

wrappers, inks, adhesives,

paper,

and

packaging

material

that comes into contact with any

cottage

food

product

must be

safe for food contact and not contaminate

the food.

Prior

to establishing a CFO in Siskiyou County, the

CFO must apply for and be issued a

permit

(CFO

Permit)

by the Community Development Department.

Further,

prior

permitting,

Water and Sewer Clearance from Environmental

Health

(if

private

water

and sewer) and

issuance

of an annual business license from

the County Treasurer-Tax Collector or the local

City

Authority

will be necessary.

HOW DO I OBTAIN THE NECESSARY

FORMS?

All forms are available upon request

at the Community Development Department, located

806 S. Main Street in Yreka,

well

as on-line at

htto://www.co.siskivou.ca.us/oa e/environmental-health-division

ARE THERE ANY FEES TO PROCESS THE

APPLICATIONS?

Fees

are due for the CFO Permit, CFO Water System Permit,

and Business License

"Class

A" CFO Permit

"Class

B" CFO Permit

Business License

s45

$10s

Siskiyou County:

$76,

City: Refer to local City Authority

Water test

Applicants

private

water and se\,ver systems

are required to submit evidence of

certified lab

test

for

bacteria, or the county can

perform

the

test at a cost of

$50.

(Please

contact

Environmental Health for details).

Checks should be made

payable

to Siskiyou

County.

Please

note that applicants may request

a verirication of fees,

and the County will

provide

a written breakdown

of the fees within 45

days of the request.

lf a cottage food

product

served by a food facility without

packaging

labeling,

it shall be

identified

to the consumer as

"Homemade"

on lhe menu, menu board, or other location

that

would reasonably

inform a consumer of its homemade

status.

WHAT PERMITS AND/OR

LICENSES ARE NEEDED TO ESTABLISH

A CFO?

HOW LONG WILL THIS PROCESS TAKE?

Application

processing

times vary depending on whether the CFO requires an initial inspection.

Where

"Class

CFO

proposed,

the

process

may take between

and

'15

days. ln cases

where

"Class

B" CFO is

proposed,

the

process

may take between

'15

and 30 days depending

upon when the initial inspection is scheduled. However, timelines can become substantially

longer should incomplete application(s) be submitted.

WHO REVIEWS AND APPROVES THE APPLICATIONS?

Applications are reviewed by the Community Developmenl Department and approved by the

CD Director or his or her designee.

ARE INCOMPLETE APPLICATIONS RETURNED?

ln the

event that an application

has not

been determined to be complete and ready for

processing

within

six

(6)

months

after the date of the

first

incomplete notice, the applicant must

complete all oulstanding requirements within thirty

(30)

days of written notice to complete the

application requirements. ln the event that the applicant fails to complete the application

submittal requirements within this time frame, the application will be considered abandoned

and staff's time and costs incurred working on the

project

shall be charged against the

application filing fees, and any remaining balance shall be refunded to the applicant.

WHAT

ARE THE CONDITIONS OF THE PERMIT?

The

permit

will

become effective

days after approval and is valid only for the

person,

location,

type of food

sales, and distdbution activity specilied by that

permit,

and, unless suspended or

revoked for cause, for the time

period

indicated on the

permit.

COUNTY OF

SISKIYOU

Community Development

Department

Envi.onmental Health a PlanninB a Building

806 South Main

Street.Yreka, California 95097

{530)

841-2100. Fax

{s30)841-4076

www.co.siskiyou.co.us/poge/communily-development

GREG PLUCKER

DIRECTOR

STEPHEN KOTPACOFF, M.D.

HEALTH

OFFICER

CMHC #

CoTTAGE FOOD

OPERATTONS

(CFO)

SELF CERTIFICATION

CHECKLIST

CLASS ?" or

"8"

PHONE

DATE

NAME OF OWNER

CFO PHYSICAL ADDRESS

CFO I.4AILING ADDRESS

CLASS A CFO PERMIT

($45)

CLASS B CFO PERMIT

($105)

The following

questions

are

based on the Cottage Food Operations

(CFO)

regulations, which have

been established as

minimum

standards of health and safety for the

preparation

of approved

cottage food

products.

Facility Requirements

. Will the CFO be located in a

private

dwelling

where

the CFO operator currently resides? ... ... ... ..

2. Willthe

preparation

of cottage food

products

take

place

in a

private

kitchen within that home? ....

3. Will the CFO require

additional storage within that home?

.lfYES,willtheroomusedforstoragebeusedexclusivelyforstorage?...............

4. Will there be sleeping

accommodations within any of the areas used for

CFO

food

preparation

storage?

... . ...

Employee

and

Training

Requirements

1. Have all

persons

thatwill

prepare

and

package

CFO

products

completed the CDPH food

processor

course?

YES,

attach copies of CDPH certificates.

)...

... ..

lf NO, will all

persons

complete

the CDPH course within 3 months of CFO registration?... ... ... ...

2. Willthe CFO have more than 1 employee?

(lmmediate

family

and

household

members are not

considered employees

Sanitation Requirements

1. Will kitchen equipment and utensils used

produce

CFO

products

be cleaned and maintained ina

good

state of reparr?

2. Willall food contact surfaces, equipment, and utensils used for

preparation, packaging,

orhandling

of CFO

products

be washed, rinsed, and sanitized before

each

use?.... ... ... ... .

3. Willall food

preparation,

food, and

equipment storage areas be

maintained

free of rodents and

insects?... ... ..

List

Non Potentially

Hazardous Foods Approved for Sale by CFOs

Please indicate which of the following approved cottage food

products

the CFO will

prepare.

Baked

goods

without

cream, custard, or

meat

fillings, such as breads, biscuits, churros, cookies,

pastries.

and tortillas

2. Candy, such as brittle and toffee.

............ .........

3. Chocolate-covered nonperishable foods, such as nuts and dried fruit.

4. Dried fruit.

Dried

pasta.

6. Dry baking mrx.

7. Fruit

pies,

fruit

empanadas, and

fruit

tamales.

...............

8. Granola, cereals,

and trail mixes. ........................

Herb

blends and dried

mole

paste.

10. Honey and sweet sorghum syrup.

Continued

on next

page

COTTAGE FOOD OPERATIONS

(CFO)

SELF

CERTIFICATION CHECKLIST Page 1 of 3

NAME OF

CFO

Fira annpFq<

YES

Jams,

jellies,

preserves,

and fruit

butter that comply

with

the standard described

in Part 150

Title 21

of the Code of Federal Regulations.

12. Nut mixes

and

nut

butters.

13. Popcorn.

14. Vinegarand Mustard.

15. Roasted

coffee and dried tea.

16.

Waffle cones and

pizelles.

17.

Cotton candy.

...

18. Candied apples.

19.

Confections such as salted caramel,

fudge,

marshmallow bars, chocolate covered

marshmallow,

nuts,

and

hard

candy, or

any combination

thereof.

20. Buttercream frosting, buttercream icing, buttercream fondant, and

gum paste

that do not contain

eggs, cream,

cream cheese.

21. Dried or Dehydrated vegetables.

22. Dried vegetarian-based soup mixes. ...

23. Vegetable and

potato

chips. ...

24. Ground chocolate.

25.

Seasoning salt.

...

26. Flat icing ...

YES NO

Specific

Cottage Food Products that will be

Prepared

and Packaged for Sale:

Food Preparation

Requirements

(includes packaging

and

handling).

Please acknowledge whether the CFO

will

operate

pursuant

to the following requirements.

1. Hand

washing will

required immediately

prior

handling foods

and after engaging

in any

activity that

contaminates the hands such as after using the toilet, coughing or sneezing, eating

or smoking.

2. Warm water,

pump

soap and single use towels will be available for hand washing.

All

food

ingredients

used

the CFO

products

will

from

an approved source.

4. Potable water shall be used for hand washing, ware washing, and as an ingredient.

5. During the

preparation, packaging

handling

of CFO

products:

There will

no other domestic activities

such as family meal

preparation,

dishwashing, clothes

washing

ironing,

kitchen cleaning or

guest

entertainment in

the

home kitchen

No infants,

small children, or

pets

will be allowed in the kitchen.

No smoking will be allowed

Any

person

with

a contagious

illness

shall

refrain

from working in the CFO....

Water

Source

1. ls

your

water

source

provided

from

regulated

public

water system?

lf YES, what is the name of

the

public

water

system?

2. ls

your

water

source a

private

water

supply?

Water Supply System

subject to applicable regulations

of the California Safe Drinking

Water Act. A water

system

permit

from

the Public Health and Community Development

Department is required.

Have

you

submitted a completed CFO Water System Permit Application? .............

1. Willthe

2. Willthe

Disposal

of Waste

CFO be served by a Public

Sewer System?

...................

CFO be served by a

Private

Septic System? ...................

The

effluent

produced

from

a CFO food

production/preparation

operation may exceed

the original design

requirements

and result in

premature

septic system failure. ln the

event

of septic system

failure,

you

are required to notify

Siskiyou County Environmental

Health immediately.

Have

you

submitted a complete Water & Sewer

Clearance

form?

you

DO NOT OWN

the dwelling the CFO occupies

then the OWNER

is required

acknowledge the septic system risk from

a CFO operation:

OWNER NAME

PHONE

OWNER

SIG

COTTAGE FOOD OPERATIONS

(CFO)

SELF

CERTIFICATION

CHECKLIST Page 2

of 3

Labeling Requirements

All CFO

products

shall be labeled in complaance with

the

Federal

Food and Cosmetac Act.

2. Please confirm

the labelwill include:

The words

"Made

in the Home Kitchen" in 12-point

type.

Common name

of the

product

or a descriptive name.

Name, city,

and zip code of the Cottage Food

Operation. ...

...

... ... ... .

Registration or Permit number

and county issuing

perm

(Siskiyou

County).

. ..

. .. . .. ..

lngredients

listin descending orderbyweight................

Net weight

product

in both English

(ounces/pounds)

and metric

(grams)

units.

.....

Major allergens

(milk,

eggs,

fish,

shellfish, tree nuts, wheat,

peanuts,

and soybeans)

listed

clearly within the ingredients list

or in a separate statement. ...... ... ...............

sample label is attached. Labels

must be legible in

plain

English, must not

smear, and may

not come in direct contact

with the food

product

without

prior

approval. ... ... ... ... ... .

YES NO

Permissible

Sales Requirements

1. Will

CFO

products

be sold via direct sales? ... ... ... ..........

2. Will CFO

products

be sold via indirect sales? ...................

3. Please confrm

that

gross

annual sales of CFO

products

will be less than

$50,000

for

each

calendar

year

of operatron. .........

Registration / Permit

Requirements

Please

acknowledge that

you

understand

and accept the following:

. A

CFO

with

"Class

A" Registration may

inspected

on the basis of

a consumer complaint. A

charge may

be assessed if the

CFO

is found

to be out of compliance. . .. ... ... ... ...

2. A

CFO with a

"Class

B" Permit will

inspected

prior

to the issuance

of a

permit

and then

annually. Additional

inspections may

occur on the basis of a consumer

complaint.

3. The CFO registration

permit

is non-transferable

and valid only forthe

person,

location,

type of

food sales and distribution

activity specified. ... ...... .............

4. The

CFO must obtain a business license from

the County Treasurer-Tax

Collector or the

appropriate

otfice if located within an incorporated

city.

Zoniog Requirements

The CFO will comply with

all applicable zoning requirements. ...

CFO Owner's Statement

I have reviewed and understand

the CFO

laws

and

guidelines.

I agree

grant

access to Siskiyou County Environmental Health

to conduct an initial/routine inspection

of my cottage

food operation and/or in

the event of a consumer complaint.

I agree

notity

Siskiyou County Environmental Health

prior

modiiying

my food list, type of operation,

and/or method

of selling, distributing, or otherwise

providing

CFO

products

to the consumer or retailers, regardless

of weather the

product

is sold, consigned,

given

away.

By signing below,

the owner hereby acknowledges that all

answers

provided

herein are accurate

and that the

owner

agrees to comply wilh all

provisions

of the Califomia Homemade Food Act as

codif,ed in the Calitornia

Heatth and

Salety Code.

CFO

Owne,'s Signaaure

Dale

OFFICE USE ONLY

Date

Application ApproYed

\200

Environmenlal Health\Consumer Proteclion\Food lnspection\Cottaqe Foods\Forms\CFO

Self Certification Checklist.doc

COTTAGE FOOD OPERATIONS

(CFO)

SELF

CERTIFICATION CHECKLIST Page

3 of 3

App I i cation Rev i ewed b

Cal Code Food

Facility/Cottaqe Food Operation Water System Permit Application

TO: Siskiyou County Health Dept.

806 S. Main Sheet

Yreka, CA

96097

FROM:

The hereby makes application

(Name

of Business)

to the Public Health & Community Development Department for a Water Supply Permit to

conduct a business serviced from

privately

owned water source for a:

Food Facility as defined under the California Health and Safety Code, Section 1'13789.

Cottage Food Operation

(CFO)

that is to be registered or

permitted pursuant

to the

California Health and Safety Code, Section

114365.

Pursuant to

provisions

of the California Safe Drinking Water Act

(Health

& Safety Code,

Section 1't6270 et seq.)

Water Source / System lnformation:

1) Description

of Source

(Well,

Spring, Surface Source):

2) ls Water Treatment

provided

and if so for what is the water being treated for

3) Do

you

have a Well Completion Report

(Well

Log)? lf

so,

please

attach a copy to this

application.

4) lf the source of the water to serve this business

proposal

to be

provided

from

an offsite

source

not

subject to the California Safe

Drinking

Water Act, the supporting documents as to

the

water rights

to this source

need

to be

provided.

The

has caused the attached documents to be

(Name

of Business)

prepared

in support of this application and certifies they are true and correct

to the best

our

knowledge.

The

rees to operate and maintain

the

water

(Name

of Business)

system in such a manner

as to

insure

that water delivered is at all times

pure,

wholesome

and

potable

and to abide

by conditions of the

permit

and

provisions

of the California

Safe

Drinking

Water Act as

they

pertain

your

facility.

Signed

Dated

ENVIRONMENTAL

HEALTH

WATBR AI\D

SEWER CLEARANCE

Applicants shall include

the

following

signed statementfromthe Environmental

Health Divisionveriffingtheyhave

received sufficient information to fully

evaluate the

proposed project.

This form shall be used

for all applications

regardless of the type

of sewer

and water

supply as

part

of an application

packet

submitted to the Planning

Department. Applications will not be

accepted without

this

form.

Brief Project Description:

Applicant's Name:

Phone No

Address:

Assessor's

Parcel No.(s)

Project Location:

Engineer's Name :

Address:

Phone:_

Township Range

Section:

Fee

required:

Yes No Ifyes

amount due:

(Fee

schedule on back)

Environmental

Health will

check

the

appropriate spaces below

when they have received

wastewater disposal

and

water supply information which is adequate

for review

of the application. Sienature

of this form

bv a

Enviromental

lfealth representative

shall not be interpreted

as approval

denial

of the

proiect proposal.

you

have any

questions

regarding

this form and/or its

purposes

in the application

packet,

feel free

to contact

Environmental

Health at

(530)

841-2100.

T hereby

certifr that the

project

description

provided

to Environmental Health

for its

review is

the same

project

description that

will be submitted

to the County Planning

Department. I

understand

that changes in

the

project

not

resulting

from the

review

process

may

cause a request

for additional

information or an

incomplete

application.

Signature

Date

For

Office Use

Only

Wastewater Disposal:

N/A

Public Sewer

_On-site

Water Supply:

N/A

State

Public

Water System

_State

Small Water

System

Cal Code Water

Private WelUWater

System

CFO Water

System

Additional

Comments or Conditions:

A fee of$

has

been collected from

the applicant

A fee has

not been

collected

Based on the above information,

water and

sewer requirements

have

been

met to the Department's

satisfaction. All

documentation has been

submitted

the applicant

project

representative.

Any

changes

in the project

may result

in requests for additional

information

by this department,

REHS Signature

Name/Title

Date

tltllttlltallltallllllrllalallllllallattlrtrtltrttlllrlrttltllttlltaltltlltlltlrtllattttllt

Land

Use

Fees

Subdivision

or more

parcels)

application:

$250.00

per

application

$50.00

per parcel

site

revlew

Public report

renewal/update

(per

hour)

$100.00

$59.99

per parcel

requiring site review

Parcel

map

five

(5)

fewer

parcels:

a) 2

parcels

$125.00

$50.00

per parcel

site review

parcels

$180.00

$50.00

per parcel

site review

c) 4

parcels

$235.00

550.00

per parcel

site review

d) 5

parcels

$315.00

$50.00

per parcel

site review

Boundary Line

Adjustment

$135.00

a) Parcel merger

$65.00

Certificate of Compliance

$65.00

Planned Unit Development

$190.00

Zone

Change

$160.00

Use Permit

(field

evaluation)

$135.00

a) Organized Camp

$175.00

$50.00

per

hour building

inspection

b) Second Dwelling Housing/Elderly Housing

$135.00

Home

Occupation Use Permit

$65.00

l0) EIR

Review

$50.00

per

hour

1l) Vacation

Rental

$200.00

12) LAFCO/GPA

$1s9.00

l3) Cottage Food

Operator

Annual Permit

(CFO)

Class A:

$45.00,

Class B

$105.00

Private water supply requires bacteriological

test:

$50.00/year

l4) Administrative Review

$65.00

NOTE: For concurrently submitted land

use applications which require evaluation of the same

information for

all

the applications:

The

application

requiring the largest fee shall be assessed the fee

as specified in

1 thru 14 and an administrative

fee as required by number

shall

be assessed to the

other

application(s).

S:V00 Environmentat

Health\land Use\Land

Use Projects\Forms

& Templates\watersewerclearance

revised Feb.20l7.doc