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Chek List Inspeksi Sanitasi Sarana Air
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 DINAS KESEHATAN KABUPATEN/KOTA .......
PENGAWASAN KUALITAS AIR BERSIH

FORMULIR INSPEKSI SANITASI

JENIS SARANA : Sumur Gali

I. Keterangan Umum

1 Lokasi : PUSKESMAS …………..

Desa/kelurahan ………….
2 Kode sarana : ……………….
3 Pemilik sarana : ……………….
4 Tanggal kunjungan : …… / …… / …... Tanda tangan
5 Apakah telah diambil sampel airnya ? : Ya / Tidak
6 Nomor kode sampel air : …………….
7 Koliform per 100 ml sampel : …….. kelas … (diisi A/B/C/DE
(sesuai kelas)
8 Koli tinja per 100 ml sampel : …….. kelas ……… kualitas airnya

II. Diagnosa Khusus

Ya Tidak
1. Apakah ada jamban pada radius 10 m disekitar sumur ?
2. Apakah ada sumur pencemar lain pada radius 10 m disekitar
sumur, misalnya kotoran hewan, sampah, genangan air, dll ?
3. Apakah ada/sewaktu-waktu ada genangan air pada jarak 2 (dua)
meter sekitar sumur ?
4. Apakah saluran pembuangan air limbah rusak/tidak ada?
5. Apakah lantai semen yang mengitari sumur mempunyai radius
This website stores and accesses kurang dari 1 (satu)
information on yourmeter ? such as cookies. Personal data may be processed, such as cookie
device,
identifiers, unique device identifiers, and browser information.ada
6. Apakah ada/sewaktu-waktu genangan
Third air diatas
parties may lantai
store and semen
access information on your device and process
sekeliling sumur ?
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
7. Apakah didaerah hulu intake digunakan sebagai tempat limpahan
may not see relevant ads or personalized content.
air dari hasil You peternakan
kegiatan may change(sapi
your perah,
settings at anydan
ayam, time or accept the default settings. You may close
lain-
this banner to continue with onlylain) ?
essential cookies. Privacy Policy
Storage Preferences 8. Apakah ember dan tali timba diletakkan sedemikian rupa
Third Parties sehingga memungkan pencemaran ?
9. Apakah bibir sumur (cincin) tidak sempurna sehingga
memungkinkan air merembes kedalam sumur ?
Storage
10. Apakah dinding semen sedalam 3 (tiga) meter dari atas
permukaan tanah tidak diplester cukup rapat/tidak sempurna ?
Targeted Advertising JUMLAH

Personalization Skor resiko 8 – 10 : Amat Tinggi (AT)

pencemaran : 6–7 : Tinggi (T)
3–5 : Sedang (S)
Analytics
0-2 : Rendah (R)

III. Hasil dan saran-saran

Untuk Perbaikan pada nomor/butir 1 s/d 10

Petugas

( …………………………)
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
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Third Parties

Storage

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 DINAS KESEHATAN KABUPATEN/KOTA .......
PENGAWASAN KUALITAS AIR BERSIH

FORMULIR INSPEKSI SANITASI

JENIS SARANA : Pompa Tangan Dalam/Dangkal

I. Keterangan Umum

1 Lokasi : PUSKESMAS …………..

Desa/kelurahan ………….
2 Kode sarana : ……………….
3 Pemilik sarana : ……………….
4 Tanggal kunjungan : …… / …… / …... Tanda tangan
5 Apakah telah diambil sampel airnya ? : Ya / Tidak
6 Nomor kode sampel air : …………….
7 Koliform per 100 ml sampel : …….. kelas …… (diisi A/B/C/DE
(sesuai kelas)
8 Koli tinja per 100 ml sampel : …….. kelas ……… kualitas airnya

II. Diagnosa Khusus

Ya Tidak
1 Apakah ada jamban pada radius 10 m disekitar sumur ?
2 Apakah ada sumur pencemar lain pada radius 10 m disekitar
SPT, misalnya kotoran hewan, sampah, genangan air, dll ?
3 Apakah ada/sewaktu-waktu ada genangan air pada jarak 2 (dua)
meter sekitar sumur pompa tangan?
4 Apakah saluran pembuangan air limbah rusak/tidak ada?
5 Apakah lantai semen yang mengitari SPT mempunyai radius
kurang dari 1 (satu) meter ?
6 Apakah
This website stores and accesses ada/sewaktu-waktu
information on your device,ada genangan
such air diatas
as cookies. lantai
Personal datasemen
may be processed, such as cookie
sekeliling sumur ?
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
7 Apakah ada keretakan pada lantai semen disekeliling pompa
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
tangan?
may not see relevant ads or8personalized content.pompa
Apakah dudukan You may change
tangan your
yang settings atdengan
berbatasan any time or accept the default settings. You may close
lantai
this banner to continue with onlykurang
essential cookies. Privacy
rapat/lepas, Policy
yang memungkinkan air merembas masuk
Storage Preferences kedalam sumur pompa tangan ?
Third Parties JUMLAH

Skor resiko 8 : Amat Tinggi (AT)

Storage
pencemaran : 6–7 : Tinggi (T)
3–5 : Sedang (S)
Targeted Advertising 0-2 : Rendah (R)

Personalization
III. Hasil dan saran-saran
Untuk Perbaikan pada nomor/butir 1 s/d 10
Analytics

Petugas

( …………………………)
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
 DINAS KESEHATAN KABUPATEN/KOTA .......
PENGAWASAN KUALITAS AIR BERSIH

FORMULIR INSPEKSI SANITASI

JENIS SARANA : Tangki Penampungan Air Hujan

I. Keterangan Umum

1 Lokasi : PUSKESMAS …………..

Desa/kelurahan ………….
2 Kode sarana : ……………….
3 Pemilik sarana : ……………….
4 Tanggal kunjungan : …… / …… / …... Tanda tangan
5 Apakah telah diambil sampel airnya ? : Ya / Tidak
6 Nomor kode sampel air : …………….
7 Koliform per 100 ml sampel : …….. kelas …… (diisi A/B/C/DE
(sesuai kelas)
8 Koli tinja per 100 ml sampel : …….. kelas ……… kualitas airnya

II. Diagnosa Khusus

Ya Tidak
1 Apakah tampak ada pengotoran atap/daerah penangkap air seperti
kotoran atau sampah ?
2 Apakah saluran air yang menyalurkan air ke tangki penampungan
dalam keadaan kotor/tidak saniter ?
3 Apakah ada kekurangan dalam bak filter/penyaringan air masuk
kedalam tangki, seperti tidak ada kerikil ?
4 Apakah ada lubang pemeriksaan (manhole) yang tidak tertutup
rapat ?
5 Apakah
This website stores and accesses ada kerusakan
information di dalam
on your device, suchdinding atau atap
as cookies. tangki,
Personal data may be processed, such as cookie
misalnya keretakan, yang memungkinkan air dari luar masuk
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
kedalam tangki ?
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
6 Apakah kran air bocor atau rusak ?
may not see relevant ads or7personalized
Apakah pipacontent. You
peluap may change
berada your yang
pada posisi settings at any
tidak timeseperti
saniter or accept the default settings. You may close
this banner to continue with onlymenghadap ke atasPrivacy
essential cookies. atau tidak ditutup kasa ?
Policy
Storage Preferences 8 Apakah bak pengambilan air tidak saniter ?
Third Parties 9 Apakah ada sumber pencemar lain sekitar tangki atau daerah
pengambilan air, misalnya kotoran ?
10 Apakah ember diletakkan sedemikian rupa sehingga mungkin
Storage
dapat tercemar ?
JUMLAH
Targeted Advertising
Skor resiko 9 - 10 : Amat Tinggi (AT)
Personalization pencemaran : 6–8 : Tinggi (T)
3–5 : Sedang (S)
0-2 : Rendah (R)
Analytics

III. Hasil dan saran-saran

Untuk Perbaikan pada nomor/butir 1 s/d 10

Petugas

( …………………………)
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
 DINAS KESEHATAN KABUPATEN/KOTA .......
PENGAWASAN KUALITAS AIR BERSIH

FORMULIR INSPEKSI SANITASI

JENIS SARANA : Perlindungan Mata Air (PMA), Sumur Artesis (SA)

I. Keterangan Umum

1 Lokasi : PUSKESMAS …………..

Desa/kelurahan ………….
2 Kode sarana : ……………….
3 Pemilik sarana : ……………….
4 Tanggal kunjungan : …… / …… / …... Tanda tangan
5 Apakah telah diambil sampel airnya ? : Ya / Tidak
6 Nomor kode sampel air : …………….
7 Koliform per 100 ml sampel : …….. kelas …… (diisi A/B/C/DE
(sesuai kelas)
8 Koli tinja per 100 ml sampel : …….. kelas ……… kualitas airnya

II. Diagnosa Khusus

Ya Tidak
1 Apakah konstruksi bangunan masih memungkinkan air hujan
untuk masuk ke dalam ?
2 Apakah terdapat retak-retak pada bangunan ?
3 Apakah tidak tersedia pipa penguras ?
4 Apakah tidak tersedia pipa peluap pada bangunan ?
5 Apakah bangunan tersebut tidak dilengkapi dengan lubang
pemeriksaan (manhole)
6 Apakah manhole tidak dilengkapi dengan tutup ?
This website stores and accesses
7 Apakahinformation on your
penutup device,
manhole such
tidak as cookies.
dikunci Personal
(digembok) data may be processed, such as cookie
dengan
baik ?
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
8 Apakah semua bagian yang terbuka (peluap, pipa hawa) tidak
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
terlindung terhadap masuknya serangga / binatang ?
may not see relevant ads or personalized content. You may change your settings at any JUtime
ML or A
accept
H the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences Skor resiko 7-8 : Amat Tinggi (AT)
Third Parties pencemaran : 5 – 6 : Tinggi (T)
3–4 : Sedang (S)
0-2 : Rendah (R)
Storage

Targeted Advertising
III. Hasil dan saran-saran
Untuk Perbaikan pada nomor/butir 1 s/d 10
Personalization

Petugas
Analytics

( …………………………)
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
this banner to continue with only essential cookies. Privacy Policy
Storage Preferences
Third Parties

Storage

Targeted Advertising

Personalization

Analytics
This website stores and accesses information on your device, such as cookies. Personal data may be processed, such as cookie
identifiers, unique device identifiers, and browser information. Third parties may store and access information on your device and process
this personal data. You may change or withdraw your preferences by clicking on the cookie icon or link; however, as a consequence, you
may not see relevant ads or personalized content. You may change your settings at any time or accept the default settings. You may close
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