A.

Pipe Scheme
Province District Village

Team Code Job Code Completion Date

Donor Name Pipe Scheme Name

No. of Latrines Constructed No. of Baths Constructed

Volume (m3)

Reservoir 1 LAT LON (main reservoir)

Reservoir 2 LAT LON

Reservoir 3 LAT LON

Reservoir 4 LAT LON

Yield
Type of Catchment
(l/s)

Catchment 1 LAT LON [ ] Spring[ ] Well[ ] Drainage[ ] Other

Catchment 2 LAT LON [ ] Spring[ ] Well[ ] Drainage[ ] Other

Catchment 3 LAT LON [ ] Spring[ ] Well[ ] Drainage[ ] Other

Catchment 5 LAT LON [ ] Spring[ ] Well[ ] Drainage[ ] Other

Catchment 6 LAT LON [ ] Spring[ ] Well[ ] Drainage[ ] Other

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B. Pipe Scheme

Beneficiary
No. LAT LON Village Elder
(HH/Fam.)

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