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Latitude: Longitude:

BUILDING TYPE

Residential Commercial Educational Industrial

WATER SOURCE

Check All
Borehole Water Board From Well
From Neighbour Buying from Vendors
From Stream None Available

WATER IN COMPOUND

Yes No

IN-HOUSE TAP RUNNING

Yes No

RECORD CLASS

Current (Less than 1 month)
Recent (Less than 6 months)
Old (6 months or more)