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Example: <br />Chocolate Chip Cookies with Walnuts <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Note: For the “Issued in County" - Identify the Jurisdiction (city/county) where you are obtaining approval. <br />'2^,0 <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM <br />Ingredients: Enriched flour (wheat flour, niacin, reduced iron, thiamine, mononitrate, riboflavin <br />and folic acid), butter (milk, saltji, chocolate chips [sugar, chocolate liquor, cocoa butter, butterfat <br />(milk), v/alnuts, sugar, eggs, salt, artificial van ilia extract, baking soda <br />Made in a home kitchen <br />Net Wt. 3 oz. (85.05g) <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Permit# 012345 <br />Issued in: San Joaquin County <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />□ Public Sewer Service JZfPrivate 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: <br />^JZTPrivate 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 />cETBacteriological Test (quarterly*): <br />^Nitrate Test (yearly*): '