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(Sanitary Survey for the assessment of risk of contamination of drinking water source)
(i) ffl Jfq;R -~ m -1t'fcfiq (Shallow and deep Hand Pump)
1. fclq'{ufl ......................................... "cl'RT ...................................... 4'i41lH1 .................................................... .
~~o;g ......................................................................................... ftrc;{r ...................................................
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2. q~"1C'1 mff r6 f1CR 4Rql'{ jft.~I cpl (l1lo ;lo ~ ) ...............................................................
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3. ma- ~o (Code no) ............................................................................................................................................................ ••••

4. ¼f<ffi/4i41~ct ~/~jG I~ r6 ~R,Pt~ c p l ~ .................................................................................. .

5. l{1=JUT qft ........................................................................................................................................................................
6. <flTT ? .......................................
'q)f ~o TJm t .......................... ~1ict> ....................................
1. H o 1l 'GfTq TJm r6 cpl 24 48 tR 1l mmma-
t 3fix m m t1 x3q~1,, C'll~cf> 'ITT/~
(ii) G1~~'1 ~14>t'l'1 f¥J ffl" / ~ -ij ctR -=-
61" (Yes) (No)
1. <flTT 1C'1~4 10 r6 3TGx ~fti41C'1~ t ?
2. <flTT 1C'1~4 'q;'T ~fti41C'1~ r6 t?
( ~-llFfq " lwf / "111 <Nl r6 lfc-J-~ ) t ?
4. <flTT 1C'1~4 10 3TGx 'Gf1-T1q ?
5. <flTT 1 C'1 q 'q)f ~1 t:f cro\ t <flTT ~Rt~ fa ID TJm t I
~H1"5 cpRUT 'Gf1-T1q ID ffl t ?
6. <flTT 1C'lcJt_4 10 r6 3TGx Gil1cH '1lm t ?
1. <flTT 1C'lcJt_4 ~c4514 cpl cZJm 2 cJ>lf t ?
8. <flTT 1c,1~q ~c4514 tR 'Gf1-T1q mffi" ?
9. <flTT 1C'1~4 cpl i4i{~HI ~Rt!lta ID TJm ? t
1o. <flTT 'ffi1f Rt ~1 1 C'1 qj"q tR m .:rnm, ma ?
'1f1ft.Si r6 3Tq> (~~'I TT <TT f}1Pt~ 1) t
~~qui ffiR cf>T 'ilqGo~ : (ttct>i-<ic'ict> {6T) 311'clR tR) :
(i) 9-10 (ii) 6-8 'ffcJ> (iii) 3-5 (iv) 0-2 ~1ctSi
(iii) qR 0 11¥i 31N ~$liq :
(1) (10) cf"q; G1~f'&+i q;1" -=ITc q;x 'ti~GI~ 'lIT cZJfcffi q;1" 1flTT I
ffi cfIB &:I f«i cf>T -il+r, 6ffi lffi 1 iq, ......................................................................................................
Note :- 'fi~f4:>a Qfacl~1 ~Rti3t al~ clR / '{~1~1~ / ~~1,1~11c-11 ~131~¢ cpl ~ffi r6 I

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