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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Perri t# C12545 <br />Issued -n: San Jcaqu -n County <br />Chocolate Chip Cookies with Walnuts <br />Iraredierta: Erriched flour ti,•,heat niadr, reduced in: r, thiarr ir e, rrcrcritimre, ribcfle <br />er fclic ac id butter Imlilt, lt, ch cc c late chip 'sugar, ±ccclateliqucr, cc cc butter, butterfat <br />I rr %,:al ruts, sugar, eggs, salt, artificial van ilia enract, bakirg acia <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 />%j Public Sewer Service Lii 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 />;14 Name of Public Water System or Community Services District: -1----)LAt, <br />1=I 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 />Li Bacteriological Test (quarterly*): <br />El Nitrate Test (yearly*): <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM