WASHING OR BATH FACILITES
No. of washing - bath facilites
Type(s)
( ] sink
No. dwelling _
[ ] cub
[ J] shower
[ ] other, speci
Comments
WATER SUPPLY
Source
( ] rainwater
( ] Commmity system
{ ] ground water [ ] other, mer
( ] Individual
~
{ ] Bot
Storage capability of island
No. and size of tanks or cisterns
Total gallons of capacity
If eisterns ~ catchment area
Is emergency storage availabie
Distribution
[{ ] no
[ ] piped inside house
{ ] yes, L1& yes,J capacity
[ ] piped outside
( ] other, specify
Treatment
{ ] none
([ ] filter
f ] disinfection
[ ] good
{ ] fair
( ]] peor
{ ] ne
(]] yes
Comment
Sanitary condition
Protection from contamination
Use
( ] domestic only: { ] domestic plus agriculcure
{ ] other, specify
Comments