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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Perm 012345 <br />ssued in: San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Ingredients: Er rich ed flour , hiu heat floc; r, niacin, reduced iron, thiamine, moronitrate, ritrflakein <br />and folic acid:., ater !milk, ialt,chocolate chips [sugar, chocdate liquor, cocoa butter, butterfat <br />!mil vialmts, _sugar, eggs, salt, artificial var il la extract, ba rt• sc cla <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt. 3 oz. (83.05g) <br />Note: For the "Issued in County" - Identify the jurisdiction (city/county) where you are obtaining approval. <br />Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />\ZPublic Sewer Service El Private Septic System <br />In the event of septic system failure or plumbing problem. you are required to notify San Joaquin County Environmental Health <br />Department immediately. <br />Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />\XName of Public Water System or Community Services District: C <br />Private Water Supply**, Identify the source (well, spring, surface, etc.): <br /> <br />‘‘(Up <br /> <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 />111 Nitrate Test (yearly"): <br />EHD 16-27 6:29/2023 4 CFO REG/PERMITTING FORM