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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Pe rrn -t# C12 3 4 5 <br />ssued -n: San Joaqu Ccunt.p. <br />Chocolate Chip Cookies with Walnuts <br />I rgred ie rts: Er , rich ed f 1c ur 'wheat floLr, riacir, reduced irc r, thiarr ir e, rr cc cr itrate, ribcfla vi <br />ar d fclic acid b Ltte r rril, cbocclte chips I sLgar, ch cc cl ate I iq r, cc cc a bitter. bt.tterrat <br />lrriIk .v,alruts, sLgar, e..3. 331t. artificial var il la extract, baldrg scda <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in 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 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 />Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />0,..Name of Public Water System or Community Services District: . V‘St'AACE., (X,COrtiC CzjelVL te_ <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 />9 Bacteriological Test (quarterly*): <br />9 Nitrate Test (yearly*): <br />END 16-27 6/29/2023 4 CFO REG/PERMITTING FORM