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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 95209 <br /> Perm.t#012345 <br /> ssued n San Joaqu n County <br /> Chocolate Chip Cookies with Walnuts <br /> Irgrediem,I:EnrKhedflour h heatflour,maar,redLxed iron,tMarnme,moncrerate,ribcfl3or <br /> ar d fol is SC 4.�.t utter I mi li,sale;-.Ch oC oldie C hi[5 t ui gar,&oc ol at a liquo r,mcc a b utter,butterfat <br /> Imilk,,��alnc u,cigar,eggs.salt,artificial vanilla enrad,baking scda <br /> Contains: Wheat, milk,eggs, soy, walnuts <br /> Made in a home kitchen <br /> Net Wt. 3 oz. (85.05g) <br /> Nofe;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 /> M 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 /> Name of Public Water System or Community Services District: mo"f-1►0 <br /> ❑ Private Water Supply—, Identify the source(well, spring, surfaces, etc.): ►lv 7� <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 tab,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 Pest(yearly'): <br /> EHD 16-27 6129/2023 4 CFO REGIPERMITTING FORM <br />