796 
If from well, state location, distance, and slope of ground from — 
Nearest privy 
Hogpens 
Stable 
Barnyard 
Give the approximate depth of well feet. 
How is well protected against surface drainage? 
Has the water any perceptible odor? color? taste?. 
Location j 
Is the excreta deposited directly on ground or in a receptacle? i 
If receptacle is used, is it water-tight? j 
How often are the contents of the receptacle removed and where are they de- ] 
posited? J 
Are covers provided for the seats? Is privy effectually screened? ; 
How many milch cows are usually kept? 
Have the dairy cattle been tuberculin tested? 
How are cows cleaned? How often 
Do milkers wash and wipe the udders before milking? 
Do milkers wash their hands before milking? 
■\Vhat facilities are provided, if any, in the stable or dairy, or both, for cleansing 
the hands of those persons who work with or about the cattle or handle milk 
or the dairy utensils? . 
Signature of Applicant 
Post-Office Address 
Husband’s Name 
[To be filled in if applicant is a married woman.] 
Veterinarian’s Certificate, 
[The veterinarian’s certificate must be from one who has regularly graduated from a 
veterinary medical college, or who practices under a license from a state examining 
board. If unable to secure the services of such, so state on your application blank, and, 
all other conditions being satisfactory, action will be suspended until this requirement is 
met, thus enabling you to send or bring milk into the District without violation of exist- 
ing law.] 
Sir : I have carefully examined the cattle upon the premises above referred 
to, and their condition is as follows ; 
Signature 
Address 
Personally appeared before me this day of , 19 , the subscriber,. ' 
who being duly sworn deposes and says that he is a veterinary surgeon practic- 
ing in accordance with the laws of the State in which he resides, and that he ' 
has personally examined the cattle referred to in the above statement and i 
knows them to be the same as are referred to in the application to which the ii 
certificate is appended, and that their condition is correctly described without 
evasion or concealment. 
Signature 
Address 
! 
j 
I, 
