DATA FOR SAMPLES 277 
STATE WATER SURVEY 
Department of Chemistry, University of Illinois 
Use this Certificate for water whose original source is Stream, Lake or Pond. 
Sample of water from Town.................2.. County... 0... cece ee eee 
Report to be sent tO... cee eee ene eee nen ene eeens 
Collected and sealed by... 2... ccc ccc cece ee eee eee ee ee eeenees 
Date, day and hour of collection........... 0... c cece e ccc e nee e ee ewes 
Shipped by............ cece eee Express Company. ...........c0ceeeees 
Date and hour of shipment. .......0.. 0.0 cc ccc cc ee cece eee eee enone 
Collected from... 0.0.0... 2: ceca eee eee Lecce ee tne teen eee eee seceueues 
If there have ever been any cases of Typhoid Fever among users of this water, 
state number of persons affected............. ..... Date of illness ........ 
Number of deaths ce cence tween eee cee eens What other diseases have been 
State distance... 2.2... 0. cee eee eee ee eee If the Stream is liable to pollution 
by drainage from privies, stables, feed lots, slaughter houses, factories or street 
washings, describe conditions ......... 2... cee cece cece ence eee eee 
Have there been recently any cases of Typhoid Fever on territory drained by 
Condition of Stream at present as affected by drought or recent rains or by tem- 
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Lake—Name of Lake... occ cc ce cee eee teen ene eee nn ees 
Do sewers discharge into the Lake at a point liable to pollute the water......... 
State distance from outfall of sewer to point of collection.................005- 
If this Lake is liable to pollution by drainage from privies, stables, feed lots, 
slaughter houses, factories, or street washings, describe conditions............ 
Have there recently been any cases of Typhoid Fever in territory drained into 
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Condition of Lake at present as affected by drought or recent rains or by tem- 
| Oe9 02) 010 © a 
Pond—Do tile drains discharge into it?........ Do washings from the vicinity 
of privies, stables or feed lots drain into it?.. 2.6... eee eee 
Have there recently been any cases of Typhoid Fever in region draining into it? 
Condition of Pond at present as affected by drought or recent rains or by tem- 
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