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DOH 7206(Rev.11,'85) Department of Health&Social Services <br /> Division of Health <br /> Wis.Admin.Code <br /> HSS-178 Campground Inspection Report Environmental Sanitation& <br /> Milk Certification Section <br /> NAME OF ESTABLISHMENT LOCATION CITY,VILLAGE OR TOWNSHIP n COUNTY <br /> C�}r� — ; sr L-k <br /> NAME OF LICENSEE nMAILING ADDRESS CITY,VILLAGE L D.NUMBER <br /> C;r.,3 C7 S�6 <br /> NAME OF PREVIOUS LICENSED ESTABLISHMENT NAME OF PREVIOUS LICENSED OPERATOR ESTAB.PHONE NO. RELEASE DATE <br /> Survey Date: cf r Inspection Status: License Status: OPERATOR:The violations in oper- <br /> Pre-Inspection....................................... 1 Release....................................................1 ating procedure or physical condi- <br /> Fee Status: 1st Inspection....................................... Conditional............................................2 tions indicated below must be cor- <br /> 1-25 sites.............................................1 Reg.Inspection...................................... Withhold ................................................ 3 rected by the next routine inspection <br /> 26-50 sites...........................................2 Follow Up................................................4 Suspend..................................................4 or such period of time as may be <br /> 51-100 sites.........................................3 Complaint...........................................- 5 Operational.......................................... specified. <br /> Over-100 sites....................................4 1 Other.......................................................6 Other.......................................................6 <br /> HSS 178.05 <br /> El HSS <br /> Submitted. Number of sewered sites: Total Number of Sites: Inspection Time <br /> HSS 178.06 Location HSS 178.10 Toilets <br /> 1—Well-drained—No flooding 33—0) Primitive campground <br /> 2—No drainage from source of filth 34—(2) Developed campground-sex designation <br /> HSS 178.07 Physical Layout 35 (2) 75 ft.to a campsite <br /> 3—0) Designated-numbered 36 (2) For handicapped-10% <br /> 4—(21 Separation-No permanent foundation 37 (2) Enclosed stools �10TM-pt V-(Fp" <br /> 5—(3) Density 38—(2) Urinals in male toilet rooms <br /> 6—(3) (a) Existing density 39 (3) 400 ft.maximum <br /> 7—(3) (b) Variance for greater density 40—(3) Walkways <br /> 8—(4) Recreation area maintained safe 41 (4) Number <br /> 9—(S) Setback from public streets HSS 178.11 Sanitary Station <br /> 10—(6) (a) Parking areas have safe access 42—Number,design,signs,location <br /> 11—(6) (b) Access to sites adequate HSS 178.12 Service Building <br /> 12—(6) (c) Internal street widths 43 0) Construction complies with ILHR <br /> 13—(6) (d) Off-street parking sufficient 44—(2) (aXbXc)Required number of fixtures <br /> HSS 178.08 Water Supply 45 (3) Self-contained R.V.campground <br /> 14-0) (a) Adequate safe supply HSS 178.13 Garbage and Refuse <br /> 15—0) (b) Public supply-connection 46 (U (a) Protected from insects and rodents <br /> 16 0) (c) Well compliance 47-0) (b) Number of containers <br /> 17-0) (d) Sampling frequency 48-0) (c) Containers emptied and cleaned <br /> 18-0) (e) Bacteriologically safe-disinfected 49-0) (d) Burning-per state/local ordinance <br /> 19—(2) No common drinking cup 50—0) (e) Solid waste disposal site-NR 180 <br /> 20 L (3) Watering station(s)-protection 51—(2) Primitive campground <br /> 21 (4) (a) Riser pipe construction 52—HSS 178.14 Fire Protection <br /> 22—(4) (b) Riser pipe termination-18"-turndown HSS 178.15 Management <br /> 23—(4) (c) Frost protection <br /> 24—(4) (d) No underground stop/waste valves 53—(1) General sanitation <br /> 25 (4) (e) Backflow/back-siphonage protection 54—(2) Register <br /> 26 (4) (f) ILHR 82 compliance HSS 178.16 Special Event <br /> HSS 178.09 Sewage Disposal System 55—Prior application-department/agent approval <br /> 27 0) Public facility-connect when available <br /> 28—(2) (a) Private system-ILHR compliance <br /> 29—(2) (b) Replace or rehabilitate <br /> 30—(2) (c) ILHR plan approval <br /> 31—(2) (d) Plumbing fixtures connectred <br /> 32—(2) (e) Privies comply-IHLR 52.63-maintained <br /> �F c=►��t�/� Fl- S G .0 A-T 77f fz l7 Gam% 7#4-- 5,4�'S <br /> TN-f-5 c r� � c s N0T c=Coc— (D/z-/A-;K iIj <br /> r �120 <br /> i 1JL6 1-4& <br /> Signature Licensee orEmployee Sig to arhtarian <br />