To the Health Officer, District of Columbia: 
In compliance with “An act to regulate the sale of milk in the District of 
Columbia, and for other purposes,” I hereby make application for a permit to 
send or bring milk into said District from the premises described below, located 
[Give name of road, nearest cross road, and anything that will aid the inspector in 
locating premises.] 
f Whole milk. 
Number of shipments per day Total number of gallons < Skim milk. 
[Cream. 
Shipped in — Wagon Boat : Kailroad 
Time of delivery Place of delivery 
Consigned to 
Description of Premises, 
stable. 
Location : 
How far from the stable are the hogpens? 
How far from the stable is the manure stored? 
Is there any standing water near the stable? 
Is the stable used for any other than dairy purposes? 
Room for cattle: 
Size : Feet long feet wide average height, feet 
Total clear air space per stall, in cubic feet 
Floor : 
Kind : Cement Plank I 
How drained? 1 
What becomes of the drainage? ' 
Lighting and ventilation : 
Number of windows : Glass Muslin curtain 
Total number of square feet in glass windows = 
Total number of square feet in glass per stall 
Total number of square feet in muslin windows 
Total number of square feet in muslin windows per stall 
Number of adjustable windows Number of nonadjustable windows 
Ventilation other than by windows : 
Number of inlets Total area in square feet 
Number of outlets Total area in square feet 
Location of inlets = — 
Location of outlets 
Stalls : 
How many? Size of each, feet long , feet wide 
What kind of tie is used for the cattle? = 
Is bedding used for the cattle? Kind- 
Feed mangers : 
Plank Cement 
If a continuous trough in front of the line of stalls, is each animal allotted 
space separated by a partition? — 
How are feed troughs cleaned? 
