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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Penn Ittt 012345 <br />sued It San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Irerefeentx Enriched 9:6" (wheat flour, niacin, reducer!iror thiamine, monortitrate, ribeflmin <br />undid( acid), butter (wilk, salt), &apatite chits (pr, chocolate liquor, cocoa butte, butterfat <br />(mill0, %drum sug sr, eggs, salt, artificial ve itract, beairg sods <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt. 3 oz. (85.05g) <br />For the ' issued in County - - Identify the jurisdiction (city/county) where you are obtaining approval <br />Disposal of Waste: <br />Plefise check what type of treatment is used to dispose of waste <br />+0 Public Sewer Service El Private Septic System <br />'n 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: itc3 ...yoo_ 6 eth a nal 34-7 rilat(31') <br />D Private Water Supply**, Identify the source (well, spring, surface, et: U V I 4:1 <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 8) <br />esults in space provided next to type of test. <br />"(jesting frequency for transient Non-Community Water Systems after initial testing) <br />Lii Bacteriological Test (quarterly"): <br />D Nitrate Test (yearly') <br />END 16-27 8/29/2023 4 CFO REG/PERMITTING FORM