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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Perm -;t4 C12345 <br />ssued -n: San Joaqu'n Ccunt,-• <br />Chocolate Chip Cookies with Walnuts <br />Irarediertl: Er ritt ed flour Iwbeat fl r, riacir, reduced ircr. thiarrire, mcrer itrate. ri bcfla 'dr <br />ard fclic acid ..., butter cbccclate chip lauF,ar. chccclate liqucr, cccca butter, butterfat <br />....,elnLte, sugar, fg.s,salt.ertificial,er ilia extract, bktr 3,= da <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 />vs P/ea e check what type of treatment is used to dispose of waste <br />Public Sewer Service 0 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 />'Name of Public Water System or Community Services District: (.‘14,\--11- <br />ci 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 />El Bacteriological Test (quarterly"): <br />LI Nitrate Test (yearly"): <br />EHD 16-27 6/29/2023 4 CFO REGIPERMITTING FORM