APPENDIX O 



FORM B 



REPORT OF MEDICAL OFFICER OF HEALTH 



ON THE FARM IN THE OCCUPATION OF 



I. — Water Supply. — 



1. Source 'of water, whether from a public water supply, a well, a running 



stream, or other source ? 



{a) For drinking purposes. 

 (J)) For cleansing cans. 

 {c) For refrigerator. 



2. If a well, how is it supplied? What is the position of the source in 



regard to — 



{a) Farmhouse or other dwellings ? 

 {b) Cowsheds, stables, pigstyes, farmyard, etc. ? 

 \c) Arable land ? 

 id) Pasture land ? 

 (Indicate, if possible, the course of the supply with regard to a, b, c, and (/.) 



3. What are the relative levels of the source, the various buildings, etc., in 



the vicinity ? 

 (The level of a well should be taken as the point to which the water reaches.) 



Is there any possibility of contamination arising from these ? 



4. What is the depth of the well ? and distance of water below the surface ? 



5. Of what material are the sides of the well ? Are they perfectly sound ? 



6. Are the fields in the vicinity dressed with fertilisers ? If so, what is used ? 



7. For all sources of supply : is any variation noticed according to the 



seasons, e.g. notable increase after heavy rains, or diminution after 

 drought ? 



8. How is the water conveyed from source of supply ? If in pipes state 



whether they are of iron or other material. 



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