276 WATER HYGIENE 
STATE WATER SURVEY 
Department of Chemistry, University of Illinois 
Use this Certificate for water whose original source is Well, Spring or Cistern. 
Sample of water from, Town.................05. County.............000., 
Report to be sent to... 0... eee cence eee teen e eee teeeenees 
Cellected and sealed by. .... 02... cece ccc cece cece cence eee eeeeneeees 
Date, day and hour of collection. ........... 0.0... cece cece cece ee enc eeeees 
Shipped by.............ce cece eee Express Company............00eeeeeces 
Date and hour of shipment. 2.0.0.0... 0. cece cc cee cette eee cece ence neees 
Collected from... 2... ce eee ee cece cee cence eee eee e nee eeeeseeteuns 
LOCATION. 6. ec nee eee ee ee te teen tee nena tee ten eevee enes 
State proximity of privy................. cesspool.......... stable......... 
Feed lot............ dumping grounds for slops, dish water, wash water, etc. . 
Is the drainage from all these places toward or from the Well, Spring or Cis- 
If there is any other possible source of pollution, stateit..................005. 
Has the water ever been considered unsafe? ............. Why? .......... 
If there have been any cases of Typhoid Fever among users of this water, state 
number of persons affected................ Date of illness.............0..... 
Number of deaths... 0... 2... ccc ccc ccc eee cece tne eee eet eeeeneeees 
Se 2 2 a 
If cemented or cased with iron pipe, state depth to which cement or casing 
OXtENdS. 0. cece ce cece cece ence tebe cece een erteenseravecuceas 
Can small animals get into it at top?. .......... Lene e eee eneeceueeceeerves 
What care is taken in collecting and storing water?.............. 0.0000 cc0ee 
ee 2 A PS 
