CHEK LIST INSPEKSI LINGKUNGAN PERMUKIMAN

Nama Permukiman :
Pemilik Permukiman ;
Luas Tanah ;
Luas Bangunan Rumah ;
Luas Bangunan Penunjang ;
Jumlah seluruh penghuni ;
Alamat ;
Petugas Chek List ;
Dilaksanakan tanggal ;

1. Lokasi
1–2–3–4–5 Daerah tidak rawan bencana
1–2–3–4–5 Bukan daerah bekas TPA / tambang
1–2–3–4–5 Tidak daerah rawan kecelakaan

2. Kualitas Udara, Kebisingan & Getaran

1–2–3–4–5 Kebisingan 45 s/d 55 dbA
1–2–3–4–5 Gas berbau (H2S & NH3) tak terdeteksi
1–2–3–4–5 Debu diameter < 10 g < 150g/m3
1–2–3–4–5 Gas SO2 < 0,10 ppm
1–2–3–4–5 Debu terendap < 350 mm3/m2/hari
1–2–3–4–5 Getaran < 10 mm/detik

3. Kualitas Tanah
1–2–3–4–5 Timah hitam (Pb) < 300 mg/kg
1–2–3–4–5 Arsenik total < 100 mg/kg
1–2–3–4–5 Cadmium < 20 mg/kg
1–2–3–4–5 Benzo (a) pyrene < 1 mg/kg
1–2–3–4–5 Tidak becek
1–2–3–4–5 Tidak menimbulkan debu

4. Kualitas Air Tanah

1–2–3–4–5 Memenuhi persyaratan golongan B

5. Sarana & Prasarana Lingkungan

1–2–3–4–5 Taman
1–2–3–4–5 Tempat bermain anak
1–2–3–4–5 Rekreasi
1–2–3–4–5 Sarana drainase
1–2–3–4–5 Jalan
 1–2–3–4–5 trotoar
1–2–3–4–5 Jembatan berpagar
1–2–3–4–5 Lampu jalan
1–2–3–4–5 Sarana air / kuantitas mencukupi
1–2–3–4–5 Kualitas air sesuai peraturan
1–2–3–4–5 Sarana pengelolaan tinja
1–2–3–4–5 Sarana pengelolaan limbah domestik
1–2–3–4–5 Pengelolaan sampah
1–2–3–4–5 Pelayanan umum keamanan
1–2–3–4–5 Pelayanan umum kesehatan
1–2–3–4–5 Pelayanan umum komunikasi
1–2–3–4–5 Pelayanan tempat kerja
1–2–3–4–5 Pelayanan tempat hiburan
1–2–3–4–5 Pelayanan tempat pendidikan
1–2–3–4–5 Pelayanan kesenian
1–2–3–4–5 Sarana olah raga
1–2–3–4–5 Pengaturan jaringan listrik penuhi syarat
1–2–3–4–5 Energi listrik memenuhi syarat
1–2–3–4–5 TPM layak

6. Binatang Penular Penyakit & Pengganggu

1–2–3–4–5 Tidak terdapat sarang tikus
1–2–3–4–5 Tidak dijumpai lalat
1–2–3–4–5 Tidak dijumpai nyamuk
1–2–3–4–5 Angka jentik nyamuk <5%
1–2–3–4–5 Tidak terdapat hewan mengidap rabies
1–2–3–4–5 Aman hewan berbisa
1–2–3–4–5 Tidak dijumpai insekta pengganggu

7. Penghijauan
1–2–3–4–5 Berfungsi sebagai pelindung
1–2–3–4–5 Berfungsi sebagai penyejuk
1–2–3–4–5 Berfungsi sebagai keindahan
1–2–3–4–5 Berfungsi sebagai kelestarian alam
1–2–3–4–5 Tidak ada gangguan kesehatan

8. Pranata Rumah, Sarana dan Prasarana

1–2–3–4–5 Rumah dalam kelompok seragam
1–2–3–4–5 Sarana sulit dijangkau
1–2–3–4–5 Prasarana mendukung aktifitas