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EH 102 <br /> Rev. 9/78 CAMPGROUNDS AND CAMPING RESORT SURVEY REPORT <br /> DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Date of Survey Number of Sites DIVISION OF HEALTH Complete Survey <br /> Licensed PLATTING, RECREATIONAL AND ENVIRONMENTAL SERVICES SECTION Partial Survey <br /> 7 .:j�7 Provided Follow Up <br /> Name of Camp Location of Camp City, Village or Twp. County <br /> 1,0 `( T Oti i(2^ 4l2r '5%/+2 3 N %4— u <br /> Name of Owner Mailing Address �rJ J/ City, Village Zip Code Phone Number <br /> Z / 1/6 <br /> N e, Title and Address of Person Interviewed State License I.D. No. or Local Licensor <br /> NOTE: The violations in operating procedure, facilities or physical arrangement indicated below must be corrected by <br /> such period of time as may be specified. <br /> H 73.03 - CAMP PLAN <br /> I We - ra ne Area <br /> 2 (1) Not Subject to Flooding <br /> 3 (2) Soil and Ground Cover <br /> (3) Separation <br /> (4) Density Requirements <br /> �— (5) Recreation Area <br /> r— (6) Street Setbacks <br /> 3— (7)(a) Safe Vehicular Access <br /> 7— (7)(a) Street Alignment and Grade <br /> T3 (7)(a) Street Surfacing <br /> TT— (7)(b) Access to Camp Spaces A� <br /> T'3 (7)(c) Internal Street Widths <br /> 13 (7)(d) Off-street Parking 11 <br /> H 78.04 - WATER SUPPLY <br /> 14 a Adequate Safe Supply <br /> T3 (1)(b) Commnity Supply <br /> Tr_ (1)(c) Non-community Supply <br /> TT— (I)(d) System Disinfected �S- � � �Ln /'/0 J <br /> 3 � <br /> T (1 (d) Bacteriologically <br /> Safe <br /> 19 (2) Outlet Location <br /> 7r— (3) Vessels and Faucets <br /> 1— (4) water Station(s) <br /> 77 — (5)(a) Riser Pipe Protection <br /> 27— (5)(b) Riser Pipe. Dia, Termination }� �- <br /> 24 (5)(c) Piping Frost Protection ( �(s ) �TZ� ! vme- J4/V <br /> 25 (5)(d) Valve Installation <br /> T6 — (5)(e) Capped Outlets <br /> 17— (5)(e) Backf lo%4 Preventers <br /> 77— (5)(f) Code Compliance <br /> H 78.05 - TOILETS <br /> 29 l amp <br /> 30 (2) Developed Camp -L-J 0 (� p <br /> C—A/J <br /> 3T_ (3) Distance to Toilet <br /> 'j'£— (4) Number ,//� <br /> 37— (5) Self-containTed11-.P— l//`iL--V�L �/�� OC'C.CJ/L) C✓ ��}�l <br /> H 78.06 - SANITARY STATION ^ p <br /> 34 um a H er S l P4 C-j !3, <br /> TIM (1)(a) Uesiqn an ocation <br /> 3 (1)(b) Exemption <br /> 37— (2) Sewage Disposal <br /> II 78.07 - SERVICE BUILD114G / <br /> 38 Location <br /> (2) Fixture Requirements, (lumber of Men's T_, U_,L_,S <br /> 7+�— (3) Self-contained R.V. Camp Women's T ,L ,S <br /> H 78.08 - SOLIU WASTE DISPOSAL <br /> 41 a Developed Camp <br /> 77— (1)(b) Exemption <br /> 7— (2) Primitive Camp <br /> 4> _ H 78.09 - FIRE PROTECTION AND SAFETY <br /> H 78.10 - MANAGEMEIJ <br /> 45General anitation <br /> 7— (2) Register <br /> H 78.11 - RESPONSIBILITY OF CAMP OCCUPANTS <br /> 47Registered <br /> Ti3 (2) Camp Space Sanitation <br /> 3- (3) Proper Set-up <br /> �_ (4) Pets <br /> 3T — (5) Solid Wastes <br /> 52 (7) Flammable Material <br /> (II) ire Protection Safety <br /> Signature of Owner or Owner's Renresentative Signa ure o Person on ti g Survey <br />