Format Request Pekerjaan Konstruksi

DAFTAR NO.
URUT IJIN PEKERJAAN
LOKASI : BENDUNGAN BERINGIN SILA
No Nomor Ijin Pelaksanaan Nomor Ijin Pelaksanaan Refisi TANGGAL IJIN Perihal Refisi Keterangan
1 01 / IP / PBBS / TEK.NK-BRL-KSO / II / 2019 01 / IP / PBBS / TEK.NK-BRL-KSO / II / 2019 22/2/2019 PENGUKURAN , SPILLWAY, AKSES JALAN PENGUKURAN MAINDAM
2 02 / IP / PBBS / TEK.NK-BRL-KSO / III / 2019 14/03/2019 Galian Spillway
3 03 / IP / PBBS / TEK.NK-BRL-KSO / III / 2019 15/03/2019 Stripping Jalan
4 04 / IP / PBBS / TEK.NK-BRL-KSO / III / 2019 15/03/2019 Timbunan Jalan (All STA)
5 05 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 4/4/2019 Timbunan Jalan (STA. 3+975 sd STA. 4+125)
6 06 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 11/4/2019 Trial Timbunan Jalan
7 07 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 11/4/2019 Ijin pekerjaan Timbunan Jalan
8 08 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 Galian Spillway STA. 300 sd 440
9 15 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 2/5/2019
10 16 / IP / PBBS / TEK.NK-BRL-KSO / IV / 2019 10/5/2019 Pertemuan Galian Spillway & Outlet
11 26 / IP / PBBS / TEK.NK-BRL-KSO / V / 2019 20/5/2019 Galian Spillway (STA. 200 sd STA. 340)
12 27 / IP / PBBS / TEK.NK-BRL-KSO / V / 2019 23/5/2019 Galian Spillway (Breksi Tuff)
13 29 / IP / PBBS / TEK.NK-BRL-KSO / VII / 2019 8/7/2019 Shotecrete
14 30 / IP / PBBS / TEK.NK-BRL-KSO / VII / 2019 8/7/2019 Wiremesh
15 31 / IP / PBBS / TEK.NK-BRL-KSO / VII / 2019 27/7/2019 Jalan Akses
16 33 / IP / PBBS / TEK.NK-BRL-KSO / VIII / 2019 8/12/2019 Trial Embankmen Jalan LPB
17
PEKERJAAN : PEMBANGUNAN BENDUNGAN TANJU DAN BENDUNGAN MILA
LOKASI : KABUPATEN DOMPU
IJIN PELAKSANAAN
NO. : .............. / IP / PBML / TEK.NK-HK-KSO / ............ / ...............
Tanggal Ijin :
Macam Pekerjaan : Bagian Pekerjaan :
URAIAN PEKERJAAN
Lokasi Pekerjaan : Waktu Pelaksanaan :
I Dasar Pelaksanaan :: Check

GambarList
Kerja : Ada Tidak Ada No.Gambar : ........................................ Personil
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana 5. Laborat 9. Tukang ........orang
II Pekerjaan Perkerasan Jalan : ......................................... 2. Pelaksana 6. Logistik 10. Tukang ........orang
Lapisan Pondasi Bawah (LPB) : Sta./Patok : .....................s/d..................... : ..................... m3 3. Kepala Surveyor 7. Operator
Lapisan Pondasi Atas (LPA) : Sta./Patok : .....................s/d..................... : ..................... m3 4. Surveyor 8. Mandor
Lapis Resap Pengikat/Prime Coat : Sta./Patok : .....................s/d..................... : ..................... m2 Alat Bantu
Lapis antara (AC-BC) (Gradasi halus/kasar) (5 cm) : Sta./Patok : .....................s/d..................... : ..................... ton 1. Total Station 3. Waterpass 5. GPS
III Pekerjaan Drainase Jalan 2. Prisma 4. Bak Ukur 6. Meteran
Pekerjaan Pasangan Batu : Campuran Mortar 1.) 1 Pc : 3 Psr 2.) 1 Pc : 4 Psr (type A) Alat Berat
Estimasi Volume : ................... m3 1. ............................... Unit 3. ............................... Unit 5. ............................... Unit
Material 1.) Pc = ............zak 2.) Pasir = ............ m3 3.) Agregat= ............ m3 2. ............................... Unit 4. ............................... Unit 6. ............................... Unit
Pekerjaan Plesteran : Campuran Mortar 1.) 1 Pc : 2 Psr 2.) 1 Pc : 3 Psr

Estimasi Volume : ................... m3
Material 1.) Pc = ............zak 2.) Pasir = ............ m3
KOMENTAR
Pekerjaan Siar dengan Acian : Campuran Mortar 1.) 1 Pc : 2 Psr (Type A) 2.) 1 Pc : 3 Psr
Material 1.) Pc = ............zak
IV Peralatan : 1. ............................... unit 3. .............................. unit 5. .............................. unit
2. ............................... unit 4. .............................. unit 6. .............................. unit
V Pekerjaan Beton : Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225
Estimasi Volume : ....................... m3
Material 1.) PC = ................ Zak 2.) Pasir = ..................... m3 3.) Agregat = ................... m3
Batching Plant : ..............................................
Penulangan Besi Ulir : ............................... Estimasi Volume : ..................... Kg
Menyetujui Diperiksa Diajukan

SATKER PEMB. BENDUNGAN NT I Konsultan Kontraktor
BENDUNGAN III KSO YODYA - BRAHMA - RAYA KONSULT NINDYA - HUTAMA KSO
NURDIN, A.Md.T MARYONO BONY ARDY BAGYO

NIP. 1960 05 25 2005 04 1 001 TEAM LEADER OFFICE ENGINEER
PEKERJAAN : PEMBANGUNAN BENDUNGAN TANJU DAN BENDUNGAN MILA
LOKASI : KABUPATEN DOMPU
IJIN PELAKSANAAN
NO. : .............. / IP / PBML / TEK.NK-HK-KSO / ............ / ...............
Tanggal Ijin :
URAIAN PEKERJAAN

GambarList
II Pekerjaan Perkerasan Jalan : ......................................... 2. Pelaksana 6. Logistik 10. Tukang ........orang
Lapisan Pondasi Bawah (LPB) : Sta./Patok : .....................s/d..................... : ..................... m3 3. Kepala Surveyor 7. Operator
Lapisan Pondasi Atas (LPA) : Sta./Patok : .....................s/d..................... : ..................... m3 4. Surveyor 8. Mandor
Lapis Resap Pengikat/Prime Coat : Sta./Patok : .....................s/d..................... : ..................... m2 Alat Bantu
Lapis antara (AC-BC) (Gradasi halus/kasar) (5 cm) : Sta./Patok : .....................s/d..................... : ..................... ton 1. Total Station 3. Waterpass 5. GPS
III Pekerjaan Drainase Jalan 2. Prisma 4. Bak Ukur 6. Meteran
Pekerjaan Pasangan Batu : Campuran Mortar 1.) 1 Pc : 3 Psr 2.) 1 Pc : 4 Psr (type A) Alat Berat
Material 1.) Pc = ............zak 2.) Pasir = ............ m3 3.) Agregat= ............ m3 2. ............................... Unit 4. ............................... Unit 6. ............................... Unit

KOMENTAR
Material 1.) Pc = ............zak
IV Peralatan : 1. ............................... unit 3. .............................. unit 5. .............................. unit
2. ............................... unit 4. .............................. unit 6. .............................. unit
V Pekerjaan Beton : Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225
Estimasi Volume : ....................... m3
Batching Plant : ..............................................
Penulangan Besi Ulir / Polos : ............................... Estimasi Volume : ..................... Kg

SATKER PEMB. BENDUNGAN NT I Konsultan Kontraktor
BENDUNGAN III KSO YODYA - BRAHMA - RAYA KONSULT NINDYA - HUTAMA KSO
NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

NIP. 1960 05 25 2005 04 1 001 OFFICE ENGINEER
PEKERJAAN : PEMBANGUNAN BENDUNGAN BERINGIN SILA (PAKET - II)
LOKASI : KABUPATEN SUMBAWA
IJIN PELAKSANAAN
02 / IP / PBBS / TEK.NK-BRL-KSO / III / 2019
Tanggal Ijin :
URAIAN PEKERJAAN
I Dasar Pelaksanaan : Check List : Ada Tidak Ada No.Gambar : ........................................ Personil
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana 5. Laborat 9. Tukang .......... Orang
II Pekerjaan Survey : Jenis Survey : .............................................. 2. Pelaksana 6. Logistik 10. Tenaga ........... Orang
III Alat Berat : 1. ............................... unit 3. .............................. unit 5. .............................. unit 3. Kep. Surveyor 7. Operator
2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor 8. Mandor
IV Pekerjaan Tanah Alat Bantu
Pembersihan dan pembongkaran dengan Alat : Sta./Patok : .....................s/d..................... 1. Total Station 3. Waterpass 5. Meteran
Pengupasan Lap.Top Soil (Stripping) dengan Alat : Sta./Patok : .....................s/d..................... 2. Prisma 4. Bak Ukur 6. GPS
Galian Spillway : Sta./Patok : .....................s/d..................... Jenis Tanah :.................................. Alat Boring Hole dan Grouting
Backfill : Sta./Patok : .....................s/d..................... :.................................. 1. Grouting Mixer ........... unit 4. Stik Bor................ unit 7. Perancah ........... unit
: Sta./Patok : .....................s/d..................... :.................................. 2. Grouting Pump ........... unit 5. Tripot .................. unit 8. ...............................
V Tes Pendukung Perencanaan 3. Mesin Pompa Air ........ unit 6. Takel .................. unit 9. ...............................
Lage Scale Direct Shear Test : ............... test ; Sta./Patok : .....................s/d.....................
URAIAN
Grouting Test : ............... titik ; Sta./Patok : .....................s/d.....................
VI Pekerjaan Pemboran dan Grouting (KONDUIT, SPILLWAY)
Pemboran Lubang : Blangket Grouting Curtain Subcurtain

Kedalaman : 0 - 15 m Kedalaman : 15 - 25 m Kedalaman : 10 - 15 m
Pemboran : Pilot hole (10-20m) check hole (10-20 m)
VII Pekerjaan Pemboran dan Grouting (MAINDAM)

KOMENTAR
Kedalaman : 0-10 m Kedalaman : 10 m Kedalaman : 15 m
Pemboran : Pilot hole (10-20m) Pilot hole (20-30 m)
Check hole (10-20 m) Check hole (20-30 m)
Water Pressure Tes untuk curtain grouting (1 tekanan) : ........... Titik
Water Pressure Tes untuk lubang pilot hole dan check hole (7 tekanan) : ........... Titik
VIII Pekerjaan Pengeringan :.....................................................

PEMBANGUNAN BENDUNGAN Pengawas Pekerjaan Konsultan Kontraktor
PENGAWAS LAPANGAN BENDUNGAN INDRA BINA TUAH. KSO NINDYA - LESTARI. KSO
….......................... .......................................................... LALU TARPI, ST Ahmad Taris, ST

SITE ENGINEER
IJIN PELAKSANAAN
NO.
NO. : .............. / IP / PBBS / TEK.NK-BRL-KSO / ............ / ...............
Tanggal Ijin :
URAIAN PEKERJAAN
Galian : Sta./Patok : .....................s/d..................... Jenis Tanah :.................................. Alat Berat
: Sta./Patok : .....................s/d..................... :.................................. 1. ......................... Unit 3. ....................... Unit 5. ..................... Unit
V Tes Pendukung Perencanaan

URAIAN

Kedalaman : 15 m Kedalaman : 15 m Kedalaman : 15 m

KOMENTAR


SATKER PEMB. BENDUNGAN NT I Pengawas Pekerjaan Konsultan Kontraktor
BENDUNGAN III BENDUNGAN III KSO YODYA - BRAHMA - RAYA KONSULT NINDYA - HUTAMA KSO
SIGIT TRIHARSO, ST NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

NIP. 19580628 199003 1 005 NIP. 1960 05 25 2005 04 1 001 OFFICE ENGINEER
IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN
: Sta./Patok : .....................s/d..................... :.................................. 1. Grouting Mixer ........... unit 4. Stik Bor................ unit 7. ...............................
: Sta./Patok : .....................s/d..................... :.................................. 2. Grouting Pump ........... unit 5. Tripot .................. unit 8. ...............................
V Tes Pendukung Perencanaan 3. Mesin Pompa Air ........ unit 6. Takel .................. unit 9. ...............................

URAIAN
VI Pekerjaan Pemboran dan Grouting ...........................................................

VII Pekerjaan Pemboran dan Grouting ............................................................

KOMENTAR

NURDIN, A.Md.T DIDIK WURYANTO ARDY BAGYO

NIP. 1960 05 25 2005 04 1 001 OFFICE ENGINEER
IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN
I Dasar Pelaksanaan :: Gambar

Check List
II Persiapan : ......................................... 2. Pelaksana 6. Logistik 10. Tenaga ........orang

Pembersihan : Sta./Patok : .....................s/d..................... 3. Kepala Surveyor 7. Operator
Uitzet/Pengukuran dan Bouwplank : Sta./Patok : .....................s/d..................... : ..................... m' 4. Surveyor 8. Mandor

III Pekerjaan Tanah Alat Bantu
Galian Tanah : Sta./Patok : .....................s/d..................... : ..................... m3 1. Total Station 3. Waterpass 5. GPS
Urugan Tanah Kembali : Sta./Patok : .....................s/d..................... : ..................... m3 2. Prisma 4. Bak Ukur 6. Meteran
IV Pekerjaan Drainase Jalan / Gorong-Gorong Alat Berat
Pekerjaan Pasangan Batu : Campuran Mortar 1.) 1 Pc : 3 Psr 2.) 1 Pc : 4 Psr (type A) 1. ............................... Unit 3. ............................... Unit 5. ............................... Unit
Material 1.) Pc = ............zak 2.) Pasir = ............ m3 3.) Agregat= ............ m3

URAIAN

Material 1.) Pc = ............zak
V Peralatan : 1. ............................... unit 3. .............................. unit 5. .............................. unit
KOMENTAR
2. ............................... unit 4. .............................. unit 6. .............................. unit
VI Pekerjaan Beton : Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225
Estimasi Volume : ................... m3 Batching Plant : ....................................
VII Bekesting : Estimasi Volume : .............................. m2
VIII Penulangan Besi Ulir / Polos : ......................... mm ; Estimasi Volume : ...................................... Kg

SIGIT TRIHARSO, ST NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

NIP. 19580628 199003 1 005 NIP. 1960 05 25 2005 04 1 001 OFFICE ENGINEER
IJIN PELAKSANAAN
NO.
Tanggal Ijin :
URAIAN PEKERJAAN
Galian : Sta./Patok : .....................s/d..................... Jenis Tanah :.................................. Alat Berat
Backfill : Sta./Patok : .....................s/d..................... :.................................. 1. ......................... Unit 3. ....................... Unit 5. ..................... Unit

URAIAN

Kedalaman : 15 m Kedalaman : 15 m Kedalaman : 15 m

KOMENTAR


PEMBANGUNAN BENDUNGAN III Pengawas Pekerjaan Konsultan Kontraktor
PENGAWAS LAPANGAN (MILA) BENDUNGAN III KSO YODYA - BRAHMA - RAYA KONSULT NINDYA - HUTAMA KSO
SOSIAWAN SURANGGANA, ST NURDIN, A.Md.T LALU TARPI, ST I NYOMAN WISNA, ST

NIP. 19670614 200701 003 NIP. 19600525 200504 1 001 SITE ENGINEER
IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN

GambarList
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana .... Orang 5. Laborat .... Orang 9. Tukang .... Orang
II Pekerjaan Pembesian Struktur Diamater Besi: 2. Pelaksana .... Orang 6. Logistik .... Orang 10. Tenaga .... Orang
Intake Konduit : Sta./Patok : .....................s/d..................... 1. f 12 2. D13 3. D16 4. D19 5. D22 6. D25 3. Kepala Surveyor .... Orang 7. Operator .... Orang
Konduit : Sta./Patok : .....................s/d..................... 1. f 12 2. D13 3. D16 4. D19 5. D22 6. D25 4. Surveyor .... Orang 8. Mandor .... Orang
Spillway : Sta./Patok : .....................s/d..................... 1. f 12 2. D13 3. D16 4. D19 5. D22 6. D25 Alat Ukur
Outlet Konduit : Sta./Patok : .....................s/d..................... 1. f 12 2. D13 3. D16 4. D19 5. D22 6. D25 1. Total Station .... Unit 3. Waterpass .... Unit 5. GPS .... Unit
III Pekerjaan Bekesting Bahan: 2. Prisma .... Unit 4. Bak Ukur .... Unit 6. Meteran .... Unit
Intake Konduit : Sta./Patok : : .....................s/d..................... 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku Alat Bantu
Konduit : Sta./Patok : : .....................s/d..................... 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku 1. Bar Bending .......... Unit 3. Compressor ......... Unit 5. Cutting whell .... Unit
Spillway : Sta./Patok : .....................s/d..................... 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku 2. Bar Cutter .......... Unit 4. Vibrator elektrik ...... Unit 6. Catut .... Unit
Outlet Konduit : Sta./Patok : .....................s/d..................... 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku
IV Pekerjaan Pengecoran Beton
Intake Konduit : Sta./Patok : : .....................s/d.....................
Konduit : Sta./Patok : : .....................s/d.....................
Spillway : Sta./Patok : .....................s/d.....................
Outlet Konduit : Sta./Patok : .....................s/d.....................

KOMENTAR
Pengecoran Sitemix
Pekerjaan Beton : Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225
Estimasi Volume : .............................. m3 : .............................. m3 : .............................. m3
: ..............................................
Pengecoran Readymix
Batching Plant : ..............................................
: Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225


IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN

GambarList
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana .... Orang 5. Laborat .... Orang 9. Tukang ..... Orang
II Pekerjaan Tanah Alat: 2. Pelaksana ..... Orang 6. Logistik .... Orang 10. Tenaga .... Orang
Galian Pondasi 1. Exavator 2. Cangkul 3. Arco / Gerobak Sorong 3. Kepala Surveyor .... Orang 7. Operator ..... Orang
Timbunan Kembali 1. Exavator 2. Stamper 3. Cangkul 4. Surveyor ..... Orang 8. Mandor ..... Orang
III Pekerjaan Pondasi Alat: Alat Ukur
Pasangan Batu Belah 1. Concrete Mixer 2. Cangkul 3. Sendok Semen 1. Total Station .... Unit 3. Waterpass .... Unit 5. GPS ..... Unit
IV Pekerjaan Besi dan Bekesting Bahan: 2. Prisma .... Unit 4. Bak Ukur .... Unit 6. Meteran ... Unit
Pembesian Footplat 1. D. 16 2. Kawat Bendrat
Pembesian Sloof / Ringbalk 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat Alat Bantu
Pembesian Kolom / Balok / Plat 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat 1. Bar Bending .......... unit 3. Compressor ......... unit 5. Cutting whell ...... unit
Bekesting Sloof / Ringbalk 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku 2. Bar Cutter .......... unit 4. Vibrator elektrik ...... unit 6. Catut ....... unit
Bekesting Kolom / Balok 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7 4. Paku
Bekesting Plat 1. Penolfilm 2. Kaso 4/6 3. Kaso 5/7
V Pekerjaan Pengecoran Beton Bahan:
Footplat 1. D. 16 2. Kawat Bendrat
Sloof / Ringbalk 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat
Kolom / Balok / Plat 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat
KOMENTAR
Pengecoran Sitemix
Pekerjaan Beton : Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225
: ..............................................
Pengecoran Readymix
Batching Plant : ..............................................
: Type Beton 1.) Type-E/K-125 2.) Type-D/K-175 3.) Type-A/K-225


IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN
I Dasar Pelaksanaan :: Gambar

Check List
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana .... Orang 5. Laborat .... Orang 9. Tukang ..... Orang
II Pekerjaan Pasang Bata, Plesteran dan Acian Alat: 2. Pelaksana ..... Orang 6. Logistik .... Orang 10. Tenaga .... Orang
Pasang Bata 1. Cangkul 2. Sendok Semen 3. Jidar 3. Kepala Surveyor .... Orang 7. Operator ..... Orang
Plesteran dan Acian 1. Jidar 2. Raskram 3. Benang 4. Surveyor ..... Orang 8. Mandor ..... Orang
III Pekerjaan Pasang Kusen Pintu dan Jendela Alat: Alat Ukur
Pasang Kusen Pintu Pasang Daun Pintu 1. Pahat 2. Palu 3. Waterpass 1. Total Station .... Unit 3. Waterpass .... Unit 5. GPS ..... Unit
Pasang Kusen Jendela Pasang Daun Jendela 1. Pahat 2. Palu 3. Waterpass 2. Prisma .... Unit 4. Bak Ukur .... Unit 6. Meteran ... Unit
IV Pekerjaan Atap dan Penutup Atap Bahan: Alat Bantu
Pasang Rangka Atap Kayu / Beton 1. Kayu 8/12 2. Kayu 5/12 3. Kayu 5/7 4. Kayu 6/12 5. Kayu 2/20 6. f 8 1. Mesin Potong Kayu .... unit 3. Mesin Potong Keramik ... unit 5. Catut ....... unit
Pasang Penutup Atap 7. f 12 8. Bendrat 9. Spandex 10. Kaso 2/20 11. Baja Ringan 12. Multiroof 2. Stamper ..... unit 4. Cutting whell ...... unit 6. ...........................
13. Listplank
V Pekerjaan Plafond Bahan:
Rangka Plafond 1. Kayu 5/7 2. Plywood 3. Paku 4. Rangka Hollo
Plafond Plywood 1. Plywood 2. Paku
VI Pekerjaan Pasang Keramik
Pasang Keramik Bahan: 1. Keramik 40x40 2. Keramik 30x30 3. Keramik 20x20 4. Pasir 5. Semen 6. Air
Alat: 1. Mesin Potong Keramik 2. Sendok Semen 3. Benang 4. Paku 5. Waterpass
VII Pekerjaan Pengecatan
Pengecatan Bahan: 1. Cat Dinding 2. Cat Kayu 3. Plamur 4. Meni Kayu
KOMENTAR
Alat: 1. Kuas 2. Kuas Roll 3. Amplas 4. Ember Cat
: ..............................................
VIII Pekerjaan Sanitair
Pasang Kloset Jongkok Bahan: 1. Kloset Jongkok 2. Kloset Duduk 3. Semen 4. Pasir 4. Air
Alat: 1. Sendok Semen 2. Mesin Gerinda
IX Pekerjaan Instalasi Air
Pasang Instalasi Pipa Bahan: 1. Pipa f 4" 2. Pipa f 3" 3. Pipa f 3/4" 4. Pipa f 1/2" 5. Kran Air f 1/2" 6. Lem Pipa 7. Solasi Pipa
Alat: 1. Gergaji Pipa 2. Multitester 3. Tang 4. Palu 5. Solasi Kabel
X Pekerjaan Instalasi Listrik
Pasang Instalasi Listrik Bahan: 1. Kabel 2. Stopkontak 3. Saklar


IJIN PELAKSANAAN
Tanggal Ijin :
URAIAN PEKERJAAN
: Sta./Patok : .....................s/d..................... :.................................. 2. Grouting Pump ........... unit 5. Tripot .................. unit 8. Readout Vibrating .....
V Tes Pendukung Perencanaan 3. Mesin Bor ........ unit 6. Takel .................. unit 9. Pompa Air

URAIAN


KOMENTAR
VIII Pekerjaan Instrument :.....................................................


IJIN PELAKSANAAN/REQUEST
Tanggal Ijin :
URAIAN PEKERJAAN
Estimasi Volume : :
Gambar Kerja : Ada Tidak Ada 1. Kepala Pelaksana ...... Orang 5. Laborat ..... Orang 9. Tukang .......... Orang
II Pekerjaan Survey : Jenis Survey : .............................................. 2. Pelaksana ....... Orang 6. Logistik ...... Orang 10. Tenaga ........... Orang
III Alat Berat : 1. ............................... unit 3. .............................. unit 5. .............................. unit 3. Kep. Surveyor ....... Orang 7. Operator ...... Orang
2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor ......... Orang 8. Mandor ...... Orang
Pembersihan dan pembongkaran dengan Alat : Sta./Patok : .....................s/d..................... 1. Total Station ...... Unit 3. Waterpass ..... Unit 5. Meteran ..... Unit
Pengupasan Lap.Top Soil (Stripping) dengan Alat : Sta./Patok : .....................s/d..................... 2. Prisma ....... Unit 4. Bak Ukur ..... Unit 6. GPS ...... Unit
: Sta./Patok : .....................s/d..................... :.................................. 2. Grouting Pump ........... unit 5. Tripot .................. unit 8. Pompa Air .......... Unit
V Tes Pendukung Perencanaan 3. Mesin Bor ........ unit 6. Takel .................. unit 9. ...............................
URAIAN


KOMENTAR


PENGAWAS LAPANGAN BENDUNGAN INDRA KARYA BINA TUAH, KSO
KSO NINDYA LESTARI. KSO
…......................................................... …............................................... …............................................... Achmad Taris Atsarudin

SITE ENGINEER
IJIN PELAKSANAAN/REQUEST
Tanggal Ijin :
URAIAN PEKERJAAN
III Alat Berat : 1. ............................... unit 3. .............................. unit 5. .............................. unit 3. Kep. Surveyor ....... Orang 7. Operator ...... Orang
2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor ......... Orang 8. Mandor ...... Orang
Pengupasan Lap.Top Soil (Stripping) dengan Alat : Sta./Patok : .....................s/d..................... 2. Prisma ....... Unit 4. Bak Ukur ..... Unit 6. GPS ...... Unit
: Sta./Patok : .....................s/d..................... :.................................. 2. Grouting Pump ........... unit 5. Tripot .................. unit 8. Pompa Air .......... Unit
V Tes Pendukung Perencanaan 3. Mesin Bor ........ unit 6. Takel .................. unit 9. ...............................

URAIAN


KOMENTAR

PENGAWAS LAPANGAN BENDUNGAN INDRA KARYA - PETUAH AGUNG ANUGRAH. KSO NINDYA - LESTARI. KSO
…...................................................... …..................................................... .............................................................. …......................................................

REQUEST / I J I N P E L A K S A N A A N
Tanggal Ijin :
URAIAN PEKERJAAN
III Alat Berat : 1. Wheel Loader : .............. unit 3. Vibro Roller ............. unit 5. Watertank Truck ............... unit 3. Kep. Surveyor ....... Orang 7. Operator ...... Orang
2. Exavator : .............. unit 4. Bulldozer .............. unit 6. Tronton/DT ............... unit 4. Surveyor ......... Orang 8. Mandor ...... Orang
Pengupasan Lap.Top Soil (Stripping) dengan Alat : Sta./Patok : .....................s/d..................... Jenis Material :.................................. 2. Prisma ....... Unit 4. Bak Ukur ..... Unit 6. GPS ...... Unit
Galian Spillway : Sta./Patok : .....................s/d..................... :.................................. Alat Laboratorium dan Alat Bantu
Backfill : Sta./Patok : .....................s/d..................... :.................................. 1. Sandcone ........... set 3. Cangkul ...... unit 5. Ember ..... unit
Embankment / Timbunan : Sta./Patok : .....................s/d..................... :.................................. 2. Permeability Test ....... set 4. Linggis ....... unit 6.Meteran .... unit

Lage Scale Direct Shear Test : ............... test ; Sta./Patok : .....................s/d..................... URAIAN


KOMENTAR

VIII Pekerjaan Instrument :.....................................................

PENGAWAS LAPANGAN BENDUNGAN KSO YODYA - BRAHMA - RAYA KONSULT NINDYA - HUTAMA KSO
.......................................................... …............................................................ LALU TARPI, ST …..............................................................

CHECK LIST
PENGUKURAN
Pekerjaan : ............................................................... Jenis Pekerjaan : ...............................................................
Lokasi Pekerjaan : ............................................................... Tanggal : ...............................................................
Diajukan Diperiksa
No Uraian
Kontraktor Konsultan Pengawas
I. Persiapan : ada tidak ada ada tidak ada ada tidak ada
1. Gambar Kerja/Working Drawing (WD)
2. Setting dan Patok-patok
II. Material :
A. Kayu ya tidak ya tidak ya tidak
1. Ukuran dan panjang patok-patok sudah disesuaikan
2. Pengecetan pada ujung kayu sebagai marking pengukuran
3. Jumlah sesuai dengan volume yang dibutuhkan
B. Cat Minyak ya tidak ya tidak ya tidak

1. Warna cat minyak sudah disesuaikan untuk marking ukuran
III. Nama penanggung jawab lapangan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
Disetujui oleh : Diajukan Oleh

Direksi Pekerjaan Konsultan Kontraktor
Tanggal : Tanggal : Tanggal :
Administrasi Teknik
CHECK LIST
PENGUKURAN
Diajukan Diperiksa
No Uraian
II. Material :


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NIP. 19600525 200604 1 001 Administrasi Teknik

CHECK LIST
PENGUKURAN
Diajukan Diperiksa
No Uraian
II. Material :


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, Amd. T
CHECK LIST
PENGUKURAN
Diajukan Diperiksa
No Uraian
II. Material :


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, Amd. T
CHECK LIST
MOBILISASI ALAT BERAT
Diajukan Diperiksa
No Uraian
II. Peralatan
A. Exavator ya tidak ya tidak ya tidak
1. Kapasitas peralatan sudah disesuaikan dengan spesifikasi
2. Kondisi alat masih layak untuk digunakan
B. Bulldozer ya tidak ya tidak ya tidak

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, Amd. T
CHECK LIST
PEMBERSIHAN, PEMBONGKARAN DAN STRIPPING DENGAN ALAT
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, Amd. T
CHECK LIST
DIREKSI KEET
Diajukan Diperiksa
No Uraian
II. Nama penanggung jawab lapangan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, Amd. T
CHECK LIST
PEMBERSIHAN DAN STRIPPING DENGAN ALAT
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Lapangan Administrasi Teknik

CHECK LIST
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
GALIAN CONDUIT
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
GALIAN GORONG - GORONG
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
TIMBUNAN LAPISAN PONDASI BAWAH (LPB)
Diajukan Diperiksa
No Uraian
II. Peralatan
A. Bulldozer ya tidak ya tidak ya tidak
B. Vibroroller ya tidak ya tidak ya tidak

C. Watertanktruck ya tidak ya tidak ya tidak


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECKLIST INI HARUS DIISI SEBELUM KONTRAKTOR MENGAJUKAN PERMOHONAN IJIN KERJA / REQUEST
SATUAN KERJA : PEMBANGUNAN BENDUNGAN NUSA TENGGARA I BENDUNGAN III (RABABAKA KOMPLEKS) DI
KABUPATEN DOMPU
SATUAN KEGIATAN : BENDUNGAN - III
PEKERJAAN : PEMBANGUNAN BENDUNGAN TANJU DAN BENDUNGAN MILA (RABABAKA KOMPLEKS)
KONTRAK TANGGAL : HK.02.03-AS / SK-PB.III / 173 / 2015, TANGGAL 22 JUNI 2015
TAHUN ANGGARAN : 2015 - 2018
KONTRAKTOR : NINDYA - HUTAMA KSO
PEKERJAAN YANG DILAKSANAKAN :
PATOK / STA :
DIAJUKAN DIPERIKSA
NO URAIAN
KONTRAKTOR KONSULTAN PENGAWAS
I PERSIAPAN ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Gambar kerja / Shop Drawing (SD)
2 Request Pekerjaan
3 Seting dan Patok-Patok
II KESIAPAN LAHAN ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Lebar & Kedalaman Pondasi sdh cukup
2 Lahan bebas dari genangan
III MATERIAL
- SEMEN / PC ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Stock mencukupi
2 Type / Jenis Semen sudah disetujui
- PASIR ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Stock mencukupi
2 Gradasi Pasir sesuai Spesifikasi
3 Kadar Lumpur memenuhi syarat
- BATU PECAH ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Stock mencukupi
2 Mutu sesuai spesifikasi
3 Gradasi Batu Pecah sesuai spesifikasi
4 Bt Pecah / Kerikil telah bersih dari kotoran
- AIR ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Stock mencukupi
2 Bebas dari kotoran dan minyak dll
- ALAT BERAT & PERALATAN ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Truck Mixer / Beton Readymix
2 Concrete Pump
3 Slump Tes dan Kubus beton tersedia
4 Vibrator
5 Kompressor
IV CATATAN :
DISETUJUI : DIPERIKSA : DIAJUKAN

Pengawas Lapangan Pengawas Pekerjaan Konsultan Kontraktor
KSO YODYA-BRAHMA-RAYA KONSULT NINDYA-HUTAMA KSO
SOSIAWAN SURANGAMA, ST NURDIN, A.Md.T

NIP.19670614 2007001 003 NIP.19600525 2005041 001
KABUPATEN DOMPU
PATOK / STA :
DIAJUKAN DIPERIKSA
NO URAIAN
2 Request Pekerjaan
III PERALATAN PENGUKURAN ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Topcon
2 Waterpass
3 Prisma
4 Bak Ukur
5 Meteran
IV ALAT BERAT ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Ripper
2 Breaker
3 Exavator
4 Bulldozer
5 Tronton
IV CATATAN :


NIP.19670614 2007001 003 NIP.19600525 2005041 001
KABUPATEN DOMPU
PATOK / STA :
DIAJUKAN DIPERIKSA
NO URAIAN
2 Request Pekerjaan
III MATERIAL ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Material Besi sudah sesuai spesifikasi
2 Diameter Besi sudah sesuai spesifikasi
3 Panjang Potongan Besi
4 Jumlah Potongan Besi
IV ALAT BANTU ADA TDK ADA ADA TDK ADA ADA TDK ADA
1 Bar Cutter
2 Bar Bending
3 Cutting Whell
4 Catut
5 Kapur Besi
IV CATATAN :

SOSIAWAN SURANGANA, ST NURDIN, A.Md.T

NIP.19670614 2007001 003 NIP.19600525 2005041 001
KABUPATEN DOMPU
PATOK / STA :
DIAJUKAN DIPERIKSA
NO URAIAN
I PERSIAPAN : ADA TDK ADA ADA TDK ADA ADA TDK ADA
2 Request Pekerjaan
II RENCANA PENGECORAN :
NO KOMPONEN PENGECORAN VOLUME SATUAN MUTU BETON KETERANGAN
III CHECK LIST SEBELUM PENGECORAN : * Ada Ö Tidak Ada x
1. Cuaca pada saat Cor Cerah Mendung Hujan

2. Referensi Gambar Disetujui Tidak Disetujui
3. Bekesting / Cetakan Kebersihan Panjang Cetakan
Perminyakan Vertikal Cetakan Samping
Pengaku Cetakan Samping Leveling Cetakan Samping
Lebar Cetakan Kelurusan Cetakan
Tinggi Cetakan Stopcor Cetakan
4. Pembesian Dia. Tulangan Utama Selimut Beton

Dia. Tulangan Sengkang Panjang Stek Besi
Jumlah Tulangan Atas Posisi Stek Besi
Jumlah Tulangan Bawah Jarak Tulangan Utama
Beton Decking Jarak Tulangan Sengkang
Pengikatan Besi
5. Persiapan Lain-Lain Concrete Mixer Truck

Concrete Vibarator
Compressor
Terpal / Plastik Cor
IV PERMASALAHAN : :
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
V CATATAN :
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................

NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
PELAKSANAAN PEKERJAAN STRUKTUR
Diajukan Diperiksa
No Uraian
2. Setting dan Patok-Patok
II. Item Pekerjaan Pondasi
1. Cuaca pada saat Pasangan Batu Belah Cerah Mendung Hujan
2. Referensi Gambar Disetujui Tidak disetujui
3. Bouwplank Disetujui Tidak disetujui
4. Pasangan Batu Belah Panjang Lebar Tinggi
Campuran Mortar Plesteran
Elevasi Siar
Kelurusan Pasangan Acian
5. Persiapan Lain Concrete Mixer
IV. Check List sebelum Pengecoran Sloof, Kolom, Balok, Ringbalk

1. Cuaca pada saat Cor Cerah Mendung Hujan

3. Bekesting / Cetakan Kebersihan Panjang Cetakan
Peminyakan Vertikal cetakan samping
Pengaku cetakan samping Leveling cetakan samping
Lebar cetakan Kelurusan cetakan
Tinggi cetakan
4. Pembesian Dia. Tulangan utama Selimut beton
Dia. Tulangan sengkang Panjang stek besi
Jumlah Tulangan atas Posisi stek besi
Jumlah Tulangan bawah Jarak tulangan utama
Beton decking Jarak tulangan sengkang
5. Persiapan Lain Concrete Mixer Penerangan
Concrete Vibrator Terpal

Compressor * Ada Ö Tidak ada x
V. Permasalahan :
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
VI. Catatan :
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
PELAKSANAAN PEKERJAAN ARSITEKTUR
Diajukan Diperiksa
No Uraian
II. Item Pekerjaan Atap Kayu, Kusen Pintu, Kusen Jendela, Daun Pintu, dan Daun Jendela
1. Cuaca pada saat Pasangan Batu Belah Cerah Mendung Hujan
3. Bouwplank Disetujui Tidak disetujui
4. Pasangan Kusen Panjang Lebar Tinggi
5. Daun Pintu dan Daun Jendela Bahan Kayu Sambungan Kayu
Elevasi Pengecatan
Kelurusan Pasangan
5. Pasangan Kuda-Kuda Bahan Kayu / Baja Ringan Sambungan Kayu / Baja Ringan
III. Item Pekerjaan Penutup Atap

1. Penutup Atap Disetujui Tidak disetujui
IV. Check List sebelum Pasangan Keramik

1. Cuaca pada saat Pemasangan Cerah Mendung Hujan

3. Pemadatan Lantai Kebersihan Panjang Cetakan
4. Ukuran Keramik Sesuai Tidak Sesuai
5. Campuran Pasangan Sesuai Tidak Sesuai
6. Pemasangan Lebar Panjang
7. Elevasi Pasangan Keramik Sesuai Tidak Sesuai
V. Check List sebelum Pengecatan

1. Warna Cat Disetujui Tidak disetujui
2. Persiapan Lain Penerangan Genset
Alat Potong Keramik Alat Potong Kayu / Baja Ringan

* Ada Ö Tidak ada x
VI. Permasalahan :
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
VI. Catatan :
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
PEKERJAAN BORING DAN GROUTING
Diajukan Diperiksa
No Uraian
II. Peralatan
A. Grouting Mixer ya tidak ya tidak ya tidak
B. Grouting Pump ya tidak ya tidak ya tidak

C. Pompa Air ya tidak ya tidak ya tidak

III. Material
A. Semen ya tidak ya tidak ya tidak
1. Material yang digunakan sudah sesuai dengan spesifikasi
2. Jumlah material yang digunakan sesuai dengan kebutuhan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
TEST PENDUKUNG PERENCANAAN
Diajukan Diperiksa
No Uraian
II. Peralatan
A. Grouting Mixer ya tidak ya tidak ya tidak


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
LINGKUP PEKERJAAN INSTRUMENT
Diajukan Diperiksa
No Uraian
II. Lokasi Pemasangan Instrument ya tidak ya tidak ya tidak

1. Dimensi, Penampang Area sudah disesuaikan dengan gambar
2. Kedalaman Galian Lokasi Area sudah disesuaikan dengan gambar
3. Titik Area Boring sudah disesuaikan dengan gambar
4. Pembersihan Area Boring sudah dikerjakan
III. Peralatan yang digunakan

A. Readout Vibrating ya tidak ya tidak ya tidak
B. Mesin Bor ya tidak ya tidak ya tidak

IV. Bahan Material
A. Paralon 3" ya tidak ya tidak ya tidak

1. Bahan yang digunakan sudah sesuai dengan persyaratan
2. Jumlah bahan sudah sesuai yang dibutuhkan
B. Bentonite ya tidak ya tidak ya tidak

1. Bahan yang digunakan sudah memenuhi persyaratan
2. Jumlah bahan yang dibutuhkan sudah disesuaikan waktu pelaksanaan
C. Pasir ya tidak ya tidak ya tidak

1. Pasir yang digunakan sudah memenuhi persyaratan
2. Banyaknya pasir sudah disesuaikan dengan kebutuhan
D. Air ya tidak ya tidak ya tidak

1. Air yang digunakan sudah memenuhi persyaratan
2. Banyaknya air sudah disesuaikan dengan kebutuhan
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
PEKERJAAN BACKFILL
Diajukan Diperiksa
No Uraian
II. Peralatan
B. Dumptruck ya tidak ya tidak ya tidak

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................

CHECK LIST
TIMBUNAN MAIN DAM
Diajukan Diperiksa
No Uraian
3. Boring Grouting Main Dam
II. Peralatan
A. Wheel Loader ya tidak ya tidak ya tidak

C. Vibroroller ya tidak ya tidak ya tidak

D. Exavator ya tidak ya tidak ya tidak

E. Dump Truck ya tidak ya tidak ya tidak

F. Handstamper ya tidak ya tidak ya tidak

G. Watertank Truck ya tidak ya tidak ya tidak

III. Material ya tidak ya tidak ya tidak

1. Material Zone 1
2. Meterial Zone 2a (Filter Halus)
3. Meterial Zone 2b (Filter Kasar)
4. Meterial Zone 3 (Random)
5. Meterial Zone 4 (Rip Rap)

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................


NIP.19670614 2007001 003 NIP.19600525 2005041 001
CHECK LIST
GALIAN LERENG SPILLWAY
Diajukan Diperiksa
No Uraian
II. Peralatan
B. Breaker ya tidak ya tidak ya tidak


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
UITZET / PENGUKURAN DAN BOUWPLANK
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
III. Pelaksanaan Pekerjaan

A. Pemasangan Bouwplank ya tidak ya tidak ya tidak
1. Ukuran dan panjang kayu sudah disesuaikan
B. Dimensi Galian Tanah ya tidak ya tidak ya tidak

1. Panjang, Lebar, dan Tinggi sudah disesuaikan
2. Volume pekerjaan sesuai yang dibutuhkan

C. Dimensi Gorong-Gorong ya tidak ya tidak ya tidak
D. Dimensi Pasangan Batu ya tidak ya tidak ya tidak
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
GALIAN TANAH GORONG-GORONG
Diajukan Diperiksa
No Uraian
I. Nama Penanggung jawab lapangan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
II. Pelaksanaan Pekerjaan

A. Dimensi Galian ya tidak ya tidak ya tidak
1. Panjang, lebar dan kedalaman galian tanah sudah disesuaikan
B. Exavator ya tidak ya tidak ya tidak


C. Dump Truck ya tidak ya tidak ya tidak
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
PASANGAN BATU BELAH
Diajukan Diperiksa
No Uraian
I. Nama penanggung jawab lapangan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
A. Batu ya tidak ya tidak ya tidak

1. Ukuran sesuai dengan spesifikasi
B. Pasir ya tidak ya tidak ya tidak

1. Ukuran gradasi pasir sesuai dengan spesifikasi

C. Semen ya tidak ya tidak ya tidak
1. Jenis semen sesuai dengan spesifikasi
2. Jumlah sesuai dengan volume yang dikerjakan
1. Kebersihan Air sesuai dengan spesifikasi
2. Banyaknya sesuai dengan yang dikerjakan
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
PLESTERAN, SIAR DENGAN ACIAN
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Pasir ya tidak ya tidak ya tidak
B. Semen ya tidak ya tidak ya tidak


C. Air ya tidak ya tidak ya tidak
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
BEKESTING, PEMBESIAN PLAT GORONG-GORONG
Diajukan Diperiksa
No Uraian
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
A. Pemasangan Bekesting ya tidak ya tidak ya tidak

1. Ukuran dan panjang bekesting sudah disesuaikan
2. Perkuatan bekesting sudah disesuaikan
B. Pemasangan Besi ya tidak ya tidak ya tidak

1. Diameter besi sudah disesuaikan
2. Panjang penyaluran besi sudah disesuaikan
3. Jarak pemasangan besi sudah disesuaikan
4. Ikatan pembesian sudah disesuaikan
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
PENGECORAN PLAT
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Agregat ya tidak ya tidak ya tidak
1. Ukuran dan bentuk batu sesuai dengan spesifikasi
2. Kebersihan material batu sesuai dengan spesifikasi



III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
URUGAN TANAH KEMBALI
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................


III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
UITZET / PENGUKURAN DAN BOUWPLANK
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
III. Pelaksanaan Pekerjaan

A. Pemasangan Bouwplank ya tidak ya tidak ya tidak
1. Ukuran dan panjang kayu sudah disesuaikan
B. Dimensi Galian Tanah ya tidak ya tidak ya tidak


C. Dimensi Gorong-Gorong ya tidak ya tidak ya tidak
D. Dimensi Pasangan Batu ya tidak ya tidak ya tidak
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
GALIAN TANAH GORONG-GORONG
Diajukan Diperiksa
No Uraian
I. Nama Penanggung jawab lapangan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Dimensi Galian ya tidak ya tidak ya tidak
1. Panjang, lebar dan kedalaman galian tanah sudah disesuaikan
B. Exavator ya tidak ya tidak ya tidak


C. Dump Truck ya tidak ya tidak ya tidak
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Pekerjaan Konsultan Kontraktor
CHECK LIST
PASANGAN BATU BELAH
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
A. Batu ya tidak ya tidak ya tidak

1. Ukuran sesuai dengan spesifikasi


III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
PLESTERAN, SIAR DENGAN ACIAN
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Pasir ya tidak ya tidak ya tidak
B. Semen ya tidak ya tidak ya tidak


C. Air ya tidak ya tidak ya tidak
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
BEKESTING, PEMBESIAN PLAT GORONG-GORONG
Diajukan Diperiksa
No Uraian
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
A. Pemasangan Bekesting ya tidak ya tidak ya tidak

1. Ukuran dan panjang bekesting sudah disesuaikan
2. Perkuatan bekesting sudah disesuaikan
B. Pemasangan Besi ya tidak ya tidak ya tidak

1. Diameter besi sudah disesuaikan
4. Ikatan pembesian sudah disesuaikan
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
PENGECORAN PLAT
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................




III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
URUGAN TANAH KEMBALI
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................


III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

NURDIN, A.Md. T
NIP. 19600525 200604 1 001
CHECK LIST
MAINDAM (CUT OFF ABUTMENT KANAN)
Diajukan Diperiksa
No Uraian
II. Peralatan
B. Breaker ya tidak ya tidak ya tidak


1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................


CHECK LIST
PEKERJAAN PEMBORAN DAN GROUTING (CUT OFF MAINDAM ABUTMENT KANAN)
Diajukan Diperiksa
No Uraian
II. Lokasi Boring Hole dan Grouting ya tidak ya tidak ya tidak

3. Titik Area Boring dan Grouting sudah disesuaikan dengan gambar
4. Pembersihan Area Boring dan Grouting sudah dikerjakan

A. Grout Mixer ya tidak ya tidak ya tidak

IV. Bahan Material

1. Komposisi Semen sudah disesuaikan spesifikasi
2. Jenis Semen yang digunakan sudah disesuaikan
B. Air ya tidak ya tidak ya tidak
1. Air yang digunakan untuk campuran semen sudah disesuaikan
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................


CHECK LIST
PEKERJAAN PEMBORAN DAN GROUTING (KONDUIT)
Diajukan Diperiksa
No Uraian
II. Lokasi Boring Hole dan Grouting ya tidak ya tidak ya tidak


A. Grout Mixer ya tidak ya tidak ya tidak

IV. Bahan Material

1. Komposisi Semen sudah disesuaikan spesifikasi
2. Jenis Semen yang digunakan sudah disesuaikan
B. Air ya tidak ya tidak ya tidak
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................


CHECK LIST
PENGECORAN BETON LANTAI KERJA
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................



1. Type semen sudah disesuaikan dengan spesifikasi
2. Komposisi semen sudah disesuaikan dengan spesifikasi

E. Kebersihan ya tidak ya tidak ya tidak
1. Pembersihan lokasi Pekerjaan Konduit
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Lapangan
CHECK LIST
PENGECORAN BETON LANTAI KERJA
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Dimensi Area Konduit ya tidak ya tidak ya tidak
1. Dimensi galian Konduit sudah sesuai dengan gambar
2. Batas area pengecoran Konduit sudah dipasang
3. Area yang akan dilantai kerja lokasi sudah dibersihkan


2. Komposisi semen sudah disesuaikan dengan spesifikasi

III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Lapangan
CHECK LIST
PEKERJAAN FABRIKASI PEMBESIAN STRUKTUR
Diajukan Diperiksa
No Uraian
II. Peralatan yang digunakan ya tidak ya tidak ya tidak

A. Bar Cutter
B. Bar Bending ya tidak ya tidak ya tidak
III. Bahan Material

A. Besi Beton ya tidak ya tidak ya tidak
1. Diameter tulangan sudah sesuai dengan gambar dan spesifikasi
2. Kondisi material masih layak digunakan
B. Kawat Bendrat ya tidak ya tidak ya tidak

2. Kebutuhan material sudah disesuaikan kondisi dilokasi pekerjaan
IV. Pembesian
A. Fabrikasi Besi ya tidak ya tidak ya tidak
1. Dimensi pembesian sudah disesuaikan dengan gambar dan spesifikasi
2. Pemotongan besi sudah sesuai dengan gambar dan spesifikasi
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................

Pengawas Lapangan
CHECK LIST
PEMASANGAN PEMBESIAN STRUKTUR
Diajukan Diperiksa
No Uraian
II. Peralatan yang digunakan ya tidak ya tidak ya tidak

A. Bar Cutter
B. Bar Bending ya tidak ya tidak ya tidak
III. Bahan Material

A. Besi Beton ya tidak ya tidak ya tidak
1. Diameter tulangan sudah sesuai dengan gambar dan spesifikasi
B. Kawat Bendrat ya tidak ya tidak ya tidak

2. Kebutuhan material sudah disesuaikan kondisi dilokasi pekerjaan
IV. Pembesian
A. Pemasangan Besi ya tidak ya tidak ya tidak
1. Jumlah besi yang dipasang sudah disesuaikan dengan gambar
2. Jarak pemasangan besi sudah disesuaikan dengan gambar
3. Pengikatan besi sudah disesuaikan gambar dan spesifikasi
4. Panjang penyaluran besi sudah disesuaikan spesifikasi dan gambar
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................

Pengawas Lapangan
CHECK LIST
BEKESTING KONSTRUKSI KONDUIT
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................

A. Penolfilm ya tidak ya tidak ya tidak
1. Ukuran dan bentuk penolfilm sesuai dengan spesifikasi
2. Pamasangan sudah disesuai dengan gambar
B. Rangka Bekesting Kayu Kaso ya tidak ya tidak ya tidak

2. Pemasangan rangka bekesting sudah sesuai gambar
4. Perkuatan Rangka Bekesting sudah diperkuat
C. Perkuatan Rangka Bekesting Sisi Luar ya tidak ya tidak ya tidak

1. Ukuran dan panjang pipa sesuai dengan kebutuhan lapangan
2. Pemasangan pipa besi bekesting sudah diperkuat
D. Pembersihan ya tidak ya tidak ya tidak

1. Pembersihan area bidang pengecoran
III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Pekerjaan
CHECK LIST
PENGECORAN BETON
Diajukan Diperiksa
No Uraian

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................




III. Catatan :
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................

Pengawas Pekerjaan
CHECK LIST
PEKERJAAN PEMBORAN SUMUR OP
Diajukan Diperiksa
No Uraian
II. Lokasi Boring Sumur ya tidak ya tidak ya tidak


A. Mesin Bor ya tidak ya tidak ya tidak
B. Mata Bor ya tidak ya tidak ya tidak

IV. Bahan Material

A. Air ya tidak ya tidak ya tidak
1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................

Administrasi Teknik
CHECK LIST
PEMBERSIHAN DAN PENGUPASAN TOP SOIL (STRIPPING)
Diajukan Diperiksa
No Uraian
II. Peralatan

1. ...........................................................................................................................................................
2. ...........................................................................................................................................................
IV. Catatan :
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................


Format Request Pekerjaan Konstruksi

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Format Request Pekerjaan Konstruksi

Diunggah oleh

Hak Cipta:

Format Tersedia

DAFTAR NO.

URUT IJIN PEKERJAAN

LOKASI : BENDUNGAN BERINGIN SILA

I Dasar Pelaksanaan :: Check

II Pekerjaan Perkerasan Jalan : ......................................... 2. Pelaksana 6. Logistik 10. Tukang ........orang

Pekerjaan Plesteran : Campuran Mortar 1.) 1 Pc : 2 Psr 2.) 1 Pc : 3 Psr

Menyetujui Diperiksa Diajukan

NURDIN, A.Md.T MARYONO BONY ARDY BAGYO

I Dasar Pelaksanaan :: Check

II Pekerjaan Perkerasan Jalan : ......................................... 2. Pelaksana 6. Logistik 10. Tukang ........orang

Pekerjaan Plesteran : Campuran Mortar 1.) 1 Pc : 2 Psr 2.) 1 Pc : 3 Psr

Menyetujui Diperiksa Diajukan

NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor 8. Mandor

IV Pekerjaan Tanah Alat Bantu

VI Pekerjaan Pemboran dan Grouting (KONDUIT, SPILLWAY)

Pemboran Lubang : Blangket Grouting Curtain Subcurtain

VII Pekerjaan Pemboran dan Grouting (MAINDAM)

Menyetujui Diperiksa Diajukan

….......................... .......................................................... LALU TARPI, ST Ahmad Taris, ST

2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor 8. Mandor

IV Pekerjaan Tanah Alat Bantu

V Tes Pendukung Perencanaan

Grouting Test : ............... titik ; Sta./Patok : .....................s/d.....................

VI Pekerjaan Pemboran dan Grouting (KONDUIT, SPILLWAY)

VII Pekerjaan Pemboran dan Grouting (MAINDAM)

Kedalaman : 0-10 m Kedalaman : 10 m Kedalaman : 15 m

Menyetujui Diperiksa Diajukan

SIGIT TRIHARSO, ST NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor 8. Mandor

IV Pekerjaan Tanah Alat Bantu

Lage Scale Direct Shear Test : ............... test ; Sta./Patok : .....................s/d.....................

VI Pekerjaan Pemboran dan Grouting ...........................................................

VII Pekerjaan Pemboran dan Grouting ............................................................

Menyetujui Diperiksa Diajukan

NURDIN, A.Md.T DIDIK WURYANTO ARDY BAGYO

I Dasar Pelaksanaan :: Gambar

II Persiapan : ......................................... 2. Pelaksana 6. Logistik 10. Tenaga ........orang

Uitzet/Pengukuran dan Bouwplank : Sta./Patok : .....................s/d..................... : ..................... m' 4. Surveyor 8. Mandor

Galian Tanah : Sta./Patok : .....................s/d..................... : ..................... m3 1. Total Station 3. Waterpass 5. GPS

Estimasi Volume : ................... m3 2. ............................... Unit 4. ............................... Unit 6. ............................... Unit

Material 1.) Pc = ............zak 2.) Pasir = ............ m3 3.) Agregat= ............ m3

Estimasi Volume : ................... m3

VII Bekesting : Estimasi Volume : .............................. m2

VIII Penulangan Besi Ulir / Polos : ......................... mm ; Estimasi Volume : ...................................... Kg

Menyetujui Diperiksa Diajukan

SIGIT TRIHARSO, ST NURDIN, A.Md.T LALU TARPI, ST ARDY BAGYO

2. ............................... unit 4. .............................. unit 6. .............................. unit 4. Surveyor 8. Mandor

IV Pekerjaan Tanah Alat Bantu

V Tes Pendukung Perencanaan

Grouting Test : ............... titik ; Sta./Patok : .....................s/d.....................

VI Pekerjaan Pemboran dan Grouting (KONDUIT, SPILLWAY)

VII Pekerjaan Pemboran dan Grouting (MAINDAM)

Kedalaman : 0-10 m Kedalaman : 10 m Kedalaman : 15 m

Menyetujui Diperiksa Diajukan

SOSIAWAN SURANGGANA, ST NURDIN, A.Md.T LALU TARPI, ST I NYOMAN WISNA, ST

I Dasar Pelaksanaan :: Check

Outlet Konduit : Sta./Patok : .....................s/d.....................

Menyetujui Diperiksa Diajukan

SOSIAWAN SURANGGANA, ST NURDIN, A.Md.T LALU TARPI, ST I NYOMAN WISNA, ST

I Dasar Pelaksanaan :: Check

Pembesian Sloof / Ringbalk 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat Alat Bantu

Sloof / Ringbalk 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat

Kolom / Balok / Plat 1. f 8 2. f 10 3. f 12 4.D 16 5. Kawat Bendrat