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Example: <br /> BIG CAKE BAKER <br /> Stockton CA 95209 <br /> Permit#012345 <br /> Issued in: San Joaquin County <br /> Chocolate Chip Cookies with Walnuts <br /> Ingredients Enriched f[our(wheat flour,Nadr%reduced iron,thiamine,mononitrate,riboflavin <br /> andfdic acid),butter(milk,salo,chocolate chips(sugar,chocciateliquor,mmabutter,butterfat <br /> (milk},walnut.%sugar,eggs,sal;artificialvanilla e2ract,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 /> 6. Disposal of Waste: <br /> Pleasecheckwhattypeof 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 notifg;an Joaquin County Environmental Health <br /> Department immediately. <br /> 7. Water Source: <br /> Pease ldentifythewater source to be used in Cottage Food Facility(check one box) <br /> ❑ Name of Public Water System or Community Services district: City of Lodi <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): <br /> Private Water Supply: Initial Water Quality Results <br /> Check boxesbelow ifinitial water testing has beencompleted. <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 REGIPERMITTING FORM <br />