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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Perm it* 012345 <br />Issued in: San Joaquin County <br />Chocolate Chip Cookies with Walnuts <br />Ingredients: Enriched flour 'wheat flour, niacin, reduced iron, thiamine, monanitrate, riboflavin <br />and folic acid), buttermilk, I salt), di ocolate chips !sugar, chocolate liquor, cocoa butter, butterfat <br />walnuts, sugar, eggs, salt, artificial van illa extract, baldng 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 />Ple,e check what type of treatment is used to dispose of waste <br />IgPublic Sewer Service El 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 />R<Iame of Public Water System or Community Services District: - <br />I t4 IA,' I i'—f-ts es <br />Lii 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 />Lii Bacteriological Test (quarterly*): <br />I=1 Nitrate Test (yearly*): <br />END 16-27 6/29/2023 4 CFO REG/PERMITTING FORM