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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Pe ml it#012345 <br />Issued in: San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Ingredients: Enrided f lour 1wheat flour, niacin, reduced iron, thiamine, manor itrate, riboflavin <br />and folic acid), better lrri it:, salt), chtxolatechips chaxolate liquor, cocoa butt, butterfat <br />(mik walnuts, agar, eggs, salt, art ficta I van illa ettract, baking 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 />Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />Public Sewer Service DI 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 />Name of Public Water System or Community Services District: 00-3 of. <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 />El Bacteriological Test (quarterly*): <br />111 Nitrate Test (yearly*): <br />1,1 I <br />EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM