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4 END 16-27 6/29/2023 <br />CFO REGPERMITTING FORM <br />Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Perm di 012345 <br />tzued n San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />kr omens Enriched flax twhaeIflor.riaor, reduced Iron, thamr4, manor erre, r.toftwn <br />ardrcirc acr:11. baler thocolxa chps 1a4v Mac date lquor, cocoa Outer, t‘ctirtat <br />1 ,4. jIrt 4w, rai. nit. artrti aa I ar /1 la esstac, to arc soda <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt. 3 oz. (85.05g) <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 />gPublic 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 <br />Department immediate), <br />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 /CV/ 1 y VI_ • <br />`- I d(diriCt <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 />Bactenological Test (quarterly*): <br />0 Nitrate Test (yearly*): <br />1