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Example: <br />BIG CAKE BAKER <br />Stodktom CA 95209 <br />Pe rrn it# 012345 <br />Issued in: Sam Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />'ingredients: Enriithedillourfwheetilour, nacir, red6cediiror, thiarnire mcnorritrate. O134r <br />and fdiic edid),•butter:f,nillk, aIp, choccilate chccdlateqv3r, cocoabutter.,.butterfat <br />:(n111.14.,,heinuts, sac, eggs, salt, artiliciialvanilla extract, beliirg soda <br />Contains: Wheat, :milk, eggs, .soy, walnuts <br />IMade lin 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 />Public 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 />Name of Public Water System or Community Services District: <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 />LII Bacteriological Test (quarterly*): <br />El Nitrate Test (yearly*): <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM