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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 Suyyvey Number of Sites DIVISION OF HEALTH Complete Survey <br /> Licensed PLATTING, RECREATIONAL AND ENVIRONMENTAL SERVICES SECTION Partial Survey <br /> �Vx Provided Follow Up <br /> me of Camp Loca Ion of amp Cit Village or Twp. County <br /> N of Owner Mailing Address City, Village Zip Code Phone Number <br /> f i S©W Q L�- <br /> Name, 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 /> 11 73.03 - CAMP PLAN <br /> I We - ra ne Area <br /> �— (1) Not Subject to Flooding <br /> an GC <br /> � Gn _Z'-f <br /> 3 (2) Soli and Ground Cover ��'`� <br /> �— (3) Separation �� <br /> �— (4) Density Requirements /� /�� S./VT�j F I L <br /> �— (5) Recreation Area �1 ✓ <br /> T— (6) Street Setbacks <br /> $-- (7)(a) Safe Vehicular Access <br /> �— (7)(a) Street Alignment and Grade <br /> �— (7)(a) Street Surfacing <br /> TT— (7)(b) Access to Camp Spaces <br /> T7— (7)(c) Internal Street Widths <br /> 13 (7)(d) Off-street Parking <br /> ii 78.04 - WATER SUPPLY <br /> 14 a Adequate Safe Supply <br /> TT_ (1)(b) Community Supply <br /> TT- (1)(c) Non-community Supply J �� <br /> TT- (1)(d) System Disinfected <br /> T_ (I (d) Bacteriologically Safe 6//, t►J_ <br /> T9- (2) Outlet Location N <br /> (3) Vessels and Faucets CV /U <br /> 21 xv <br /> (4) Water Station(s) <br /> ZI-- (5)(a) Riser Pipe Protection <br /> 27— (5)(b) Riser Pipe, Dia, Termination N S 111Cr <br /> 24 (5)(c) Piping Frost Protection <br /> 25 (5)(d) Valve Installation <br /> = (5)(e) Capped outlets <br /> 37 - (5)(e) Backflow Preventers <br /> (5)(f) Code Compliance <br /> H 78.05 - TOILETS <br /> 29 rirutive Camp <br /> 30 (2) Developed Camp <br /> 7- (3) Distance to Toilet <br /> 71-- (4) Number <br /> — (5) Self-contained ed R.V. <br /> H 78.06 - SANITARY STATION <br /> 34 a Rum er <br /> 37- (1)(a) Design an ocation <br /> 3C— (1)(b) Exemption <br /> 33 (2) Sewage Disposal <br /> H 78.07 - SERVICE BUILDING <br /> 38Location <br /> (2) Fixture Requirements, Number of Men's T_, U_,L_,S_ <br /> rib— (3) Self-contained R.V. Camp Women's T ,L S <br /> Il 78.08 - SOLID WASTE DISPOSAL <br /> 41 a Developed Camp <br /> ITT — (1)(b) Exemption <br /> ;'T— (2) Primitive Camp <br /> �— H 78.09 - FIRE PROTECTION Ali SAFETY <br /> H 78.10 - MANAGEMEN r[CiiYEc <br /> 45General Sanitation <br /> TIT-- (2) Register �n <br /> H 78.11 - RESPONSIBILITY OF CAMP OCCUPANTS <br /> 47Registered <br /> 4 9� (2) Camp Space Sanitation <br /> 79 (3) Proper Set-up ; <br /> TO- (4) Pets <br /> 31 (5) Solid Wastes <br /> 52 (7) F1 le Material <br /> 7— (8) ire rotection and Safety <br /> ��_Ignature of Owner or Owner's ikepresentative ignature o Person Conducting Survey <br />