Name of Owner:
Number of people using the water:
The users use a latrine for defecation: Always / Usually / Sometimes / Rarely
Name of Community & Region:
Description of terrain: (Hill-side / plain)
Manufacturer: Self-made / Made by an experienced person
Name of community trainer:
Date of manufacture: (Month / Year)
Total Cost to Owner:
Source of the fine sand used to fill the pot:
Source of the water used to fill the pot:
Flow rate of bottom pot: seconds for 500ml
Flow rate with top pot: seconds for 500ml
Purity Test (if done) * : e-coli count in: e-coli count out:
Name of independent commissioner :
| No signs of leaks | Single layer of large stones on top |
|---|---|
| Filter sand is clean | 1-2” water covers stones below hole |
| Hose hole is 25” above base | Top pot is installed |
| Hose hole is not leaking | Area is clean and pot is covered |
| Hose is in proper place | Owner understands hygiene |
| Owner knows to leave cloudy water to stand before pouring into filter. |
* Filter must have been in use at least 1 month before purity test performed
Please return this to the Central Committee for return to Sand Filter Aid
