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Example: <br />BIG CAKE BAKER <br />Stockton CA 952C9 <br />Perm 012345 <br />saierl n: San JoaciWn County <br />Chocolate Chip Cookies with Walnuts <br />Ingredients: Enriched flour lv,heat flcur, riacir, reduced ircr, th lam ir e. mcncnitrate, ribcflavin <br />and fclic acid, butter Irrilk. ccclate chips Isuear, chocclateliaLcr, cc cca Cutter, tuaerfat <br />irriik), vatruts, suear, eags, salt, artificial vanilla e)etract, bakirg, rc is <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 />EfPublic Sewer Service LI 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: s-.4, ,-y .'tt 47 twt.. , 4 <br />0 Private Water Supply**, Identify the source (well, spring, surface, etc.): .5-tit 1c <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*): A/A <br />D Nitrate Test (yearly*): <br /> <br />4 CFO REGIPERMITTING FORM EI-ID 16-27 6/2912023