2408 Hwy 158 (3) LOCATION OWNER t li Cc�✓
ADDRESS OCCUPANT 1rC
Date of Inspection Reason for visit: Complaint
Number in family Routine Survey
WATER SUPPLY: GARBAGE DISPOSAL: D'Y'h?Q/1ry �/ q�7or
Type................ . Method.. ... ..... .......
Approved.... .... .....
Unapproved.. ..... .... FARM POND...............
_ (yes/no)
SEWAGE DISPOSAL: PREMISES:
Type............... �D 4/ Y p- a / Clean.......... ........
(yes/no)
Defects...... ...... `Z
MILK SUPPLY: REMARKS: o1T�"/ d 7'
t/� Q
Source........ ....... V
Average consumption.. S �^d 7' {' ���e•�
(pts per person day)
HOUSING:
Type of building.....
Number of rooms......
Screened.............
(yes no)
SANITATION RECORD PRIVATE PREMISES
Fore No. 472 (Rev. 9/68)
ADDITIONAL VISITS, COMPLAINTS, ETC.
Date Purpose of Visit
SANITATION DEFECTS CORRECTED
Date Notified Nature of Defects Time Allowed Date Corrected Remarks