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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Penn 43*(112 34 5 <br />issued in San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Inereeheres EPrRef•ed Het/ l‘vhe fleR.r. Plane, ',clued leer, tniamire, rror erne-ate, ntelavir. <br />and fee peel Porter ;milk 5740. &oeclate chcs [sugar, & occiate liquor, corns butter. butterfat <br />rn Wafrut 5, sugar C5s reirartfpaa I var da extract, taiorg .da <br />Contains: Wheat, milk, eggs, soy, walnuts <br />I rylade in a home kitchen <br />Net Wt. 3 or. (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 />OPublic 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 />or* <br />Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />11 Name of Public Water System or Community Services District: 0 ,1 <br />Led; <br />0 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 />11 Bacteriological Test (quarterly): <br />Nitrate Test (yearly): <br />EHO 16-27 609/2023 4 CFO FtEG/PERMITTING FORM