Health Report For Foster And Adoptive Parents (Page 5 of 6) in pdf

Health Report For Foster And Adoptive Parents Page 5

Iowa Department of Human Services

Foster Care Private Water Supply Survey

Applicants’ Names

Address

Well Location

Distance from:

House

Barnyard

Septic tank/cesspool/privy

Abandoned wells

Other

Drainage: Ground surface sloped away from well

Yes

On back of this form, sketch house with location of wells, garage, barn, septic tank, roads,

ponds, streams, and any other relevant features. Mark approximate distances and note

direction of slope.

Well Condition

Well top or cover tight with no signs of contamination entry

Yes

Comments:

Water Quality or Laboratory Report (Attach Report)

Coliform bacteria level

Safe

Unsafe

Nitrate level

Safe

Unsafe

Comments:

Water Treatment or Alternate Source

If water is boiled or obtained from a source other than the well, i.e. bottled or carried into the

home, explain the reason and describe source of water and method of storage

Signature of Contractor Licensing Worker

Date

470-0693 (Rev. 9/09)

Copy 1: DHS Licensing File

Copy 2: Contractor

Health Report For Foster And Adoptive Parents Page 5