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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 95209 <br /> Pe rm itti 012345 <br /> Issued in: San Joaquin County <br /> Chocolate Chip Cookies with Walnuts <br /> Ingredients:Enriched flour(wheatflour,niacin,reduced iron,thiamine,mononitrate,riboflavin <br /> and folic acid),butter(mik,salt},chocolatechips(sugar,chocolate liquor,mcaabutter,butterfat <br /> (milb,walnuts,sugar,eggs,sal;artificialvanilla etract,belong soda <br /> Contains:Wheat, milk,eggs, soy, walnuts <br /> Made in a home kitchen <br /> Net Wt. 3 oz. (85.058) <br /> Note:For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disaosal of Waste: <br /> Plea 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 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 /> lame of Public Water System or Community Services District: SCAn JU a�a t,m Co"'kr\{ i <br /> [I Private Water Supply—, Identify the source(well, spring, surface, etc.): "tom^ <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 /> EHD 16-27 612912023 4 CFO REG/PERMITTING FORM <br />