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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 95209 <br /> Perm it#012345 <br /> Issued in: San Joaquin County <br /> I Chocolate Chip Cookies with Walnuts <br /> Ingredients:Enriched flour(wheatflour,niaon,reduce iron,thiamine,mononitrate,riboflavin <br /> and folic acid),butter[milk,salt},chocolate chips[sugar,chocolate liquor,roma butter,butterfat <br /> (milk),vralnuts,sugar,eggs,salt,artifitialvanilla extract,ba0q.soda <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 /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ® Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to nolify San Joaquin County Environmontal 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 /> ❑x Name of Public Water System or Community Services District. Byron Bethany Irrigation District(111314) <br /> ❑ Private Water Supply*, Identify the source (well, spring, surface, etc.): <br /> Private Water Supply:Initial Water Quality Results <br /> Check boxes below it 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 /> HQ 16.27 0126i2023 4 CFO REGIPERM117ING FORM <br />