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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 9S209 <br /> Perm it#0_2345 <br /> ssuEd A: San Joaquin Count{ <br /> Chocolate Chip Cookies with Walnuts <br /> Irgrtbiert=Enriched fl,cr lsvhaatflcur,niacin,reduced imr,thlarrine,mwonitr_ze,ribeflavtn <br /> andfdit acidj,ttttcr Imilk,alti,tt!ccclatachlPt la yar,&ccdat=_liquor,CC CC LLttEr,k�;tterfat <br /> Imilk;,valnut�_ay3f,__ =, It artifiaa!•rar.illaeRrxt,taFin;;cd3 <br /> Contains: Wheat, milk,eggs, soy. walnuts <br /> Mode in a home kitchen <br /> Net Wt. 3 oz. (85.05g) <br /> NOW For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> A Public Sewer Service ❑ 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 /> 7. 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: oc� NOje f e�`r+meht� <br /> ❑ Private Water Supply', Identify the source (well, spring, surface, etc.); "'"''"� l! �N^-�� 1 f I ` <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 /> ❑ Bacteriological Test(quarterly*): <br /> ❑ Nitrate Test(yearly*): <br /> EHO 16-27 U29M23 4 CFO REGYPERMIT7ING FORM <br />