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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 95209 <br /> Pe nn it p 012 345 <br /> Issued in- San Joaquin county <br /> Chocolate Chip Cookies with Walnuts <br /> IW@diems:Enriched f bur lwhem flour,roadR reduced irof%thiaimr/ ,monwitrate,ribonaKn <br /> and folic acid),butter(rNk,salt),d»cohnecN s I;ugar,chocolate liquor,cocoab+xter,butterfat <br /> (milk),walnuts.sugar,eggs,salt,artificialvanifflb extract,lasing soda <br /> Contains: Wheat, milk,eggs, soy, wain uts <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 /> P7public <br /> e check what type of treatment is used to dispose of waste <br /> 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 /> Nparbnent immediately. <br /> 7. Water Source: <br /> Na <br /> Pe e Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District. Ca %' -F <br /> ❑ 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 /> ❑ Bacteriological Test(quarterly").- <br /> ❑ Nitrate Test(yearly'). <br /> LHO 16.27 6/2912023 4 CFO REWERIMIITTING FORM <br />