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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Perm t4 C12345 <br />ssued Sari Jcaqu:n County <br />Chocolate Chip Cookies with Walnuts <br />logradients: Er rid,ed fit:Ls I h eat fIct. r, riazir, red t.c.ad irr, &jar-ire, mcr cr itMtE, ribcflEjr <br />and ftlic acid,t utter I rrilk, choc.r.Iste chi pa IELE,zr, :.hccclEtE liq Lc r. cc s bLttr, ti.tErfat <br />ELF, ar, szgs, aI fiakaruII eytrar:t, t ki rF: zcda <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt. 3 oz. (85.03g) <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 rivate Septic System <br />In the event Of septic system failure or plumbing problem, you are required to notify San Joaquin County Environmental Health 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 />6RBacterio1ogica1 Test (quarterly"): <br />Nitrate Test (yearly"): <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM