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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Pe rm it# 012345 <br />issued in: San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Irgrs.-dis-ritE Er r&s-,1 thiamine. ribcflavir <br />srd fcli= 'milk, , =lips (suosr, dpoc.7.13tE I iqurr, turce7, <br />I rr , alrr m.;sar, s==It .d Li 5 isl -.Tar ills sairract., bakipg sc.ds <br />Contains: Wheat. Irlk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt 3 oz.."8.5.03g;, <br />Note: For the `Issued in County' - Identify the jurisdiction (city/county) where you are obtaining approval. <br />Disposal of Waste: <br />Plegse check what type of treatment is used to dispose of waste <br />0 Public Sewer Service LI 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 />'Z. Name of Public Water System or Community Services District: <br />LI 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 />D Bacteriological Test (quarterly*): <br />I=1 Nitrate Test (yearly*): <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM