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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 a0 PLATTING, RECREATIONAL AND ENVIRONMENTAL SERVICES SECTION Partial Survey <br /> AshProvided Follow Up <br /> Name olf Camp Location of Camp City, Village or Twp. County <br /> W cANA 6,1 (*A O f3 <br /> Name of Owner Mailing Ad ress 9E$4!5}City, Vill e Q �� Zip Code ? Phone Number <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 /> H 78.03 - CAMP PLA14 <br /> 1 Well-drained Area <br /> 2 (1) Not Subject to Flooding <br /> j (2) Soil and Ground Cover <br /> Tt— (3) Separation <br /> �- (4) Density Requirements <br /> �- (5) Recreation Area <br /> 7— (6) Street Setbacks <br /> �— (7)(a) Safe Vehicular Access <br /> �— (7)(a) Street Alignment and Grade <br /> TT— (7)(a) Street Surfacing <br /> TT— (7)(b) Access to Camp Spaces <br /> T — (7)(c) Internal Street Widths <br /> T3 (7)(d) Off-street Parking <br /> H 78.04 - WATER SUPPLY <br /> 14 a A equate Sa a Supply <br /> 15 (1)(b) Community Supply <br /> T7— (1)(c) Non-community Supply <br /> TT- (1)(d) System Disinfected <br /> T1— (1 (d) Bacteriologically Safe <br /> 19 (2) Outlet Location <br /> 3= (3) Vessels and Faucets <br /> 2T_ (4) Water Station(s) <br /> 1l— (5)(a) Riser Pipe Protection <br /> -3 (5)(b) Riser Pipe, Dla, Termination <br /> 24 (5)(c) Piping Frost Protection <br /> 25 (5)(d) Valve installation <br /> T6 — (5)(e) Capped Outlets <br /> 29 (5)(e) Backflow Preventers <br /> IT— (5)(f) Code Compliance <br /> H 78.05 - TOILETS <br /> 29Primitive ramp <br /> 30 (2) Developed Camp <br /> 37— (3) Distance to Toilet <br /> 7— (4) Number <br /> T3— (5) Self-containeec . — <br /> H 78.06 - SANITARY STATION <br /> 34 a Nun er <br /> T5'— (1)(a) Design an ovation <br /> (1)(b) Exemption <br /> 3 (2) Sewage Disposal <br /> H 78.07 - SERVICE BUILDING <br /> 38 ovation <br /> (2) Fixture Requirements, IJumber of Men's T U ,L ,S_ <br /> rib— (3) Self-contained R.V. Camp Women's T ,L ,S <br /> IJ 78.08 - SOLID WASTE DISPOSAL — — — <br /> 41 a eve ope Camp <br /> TT— (1)(b) Exemption <br /> 77— (2) Primitive Camp <br /> 7— li 78.09 - FIRE PROTECTION AND SAFETY <br /> H O - MANAGEMENT <br /> 115General Sanitation <br /> (2) Register <br /> H 78.11 - RESPONSIBILITY OF CAMP OCCUPAiJTS <br /> 47Registered <br /> ;7— (2) Camp Space Sanitation <br /> 1;9 (3) Proper Set-up <br /> -- (4) Pets <br /> 3T — (5) Solid Wastes <br /> 52 (7) Flammable Material <br /> 7_r— (8) Fire Protection and Safety <br /> Signature of Owner or Owner's Representative Signature 6f Person Conducting Survey <br />