LAPORAN BULANAN

REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II

Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 0 0
2 Kumulatif s.d. bulan ini 0 0
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0

..................., ............................
Pelapor
.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini
2 Kumulatif s.d. bulan ini

II Klasifikasi Rumah :

III Jenis SAB :

1 Jumlah Sumur gali
KK pemakai
2 SPT
KK pemakai
3 PAH
KK pemakai
4 PMA
KK pemakai
5 Hidran umum
KK pemakai
6 PP (Captering)
KK pemakai
7 Sambungan rumah perpipaan
KK pemakai
8 Air Kemasan
KK pemakai

IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
Rumah pemakai
2 Jumlah Jaga Cemplung
Rumah pemakai
3 Jumlah Jaga Plengsengan
Rumah pemakai
4 Lain-lain
Rumah pemakai

VII SPAL Diperiksa :

1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
L P L P L P L P L P L P L P L P L P L P L P L P L P L P
L P L P L P L P L P L P L P L P L P L P L P L P L P L P
 Total
L P
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 0 0
2 Kumulatif s.d. bulan ini 0 0
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini
2 Kumulatif s.d. bulan ini 0 0
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : KAWALELO
Bulan : FEBRUARI 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 3 0
2 Kumulatif s.d. bulan ini 3 0
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 3 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 9 3
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 8 3
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 1 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 9 3
2 Jumlah Rumah pemakai SPAL 9 3
 KAWALELO,23-2-2021
Pelapor

NI KOMANG TUTI SUSANTI

 22-2-21
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 3
2 Kumulatif s.d. bulan ini 3 0
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum 3
0 KK pemakai
6 PP (Captering)
0 KK pemakai 9 3
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 8 3
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan 1
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 9 3
2 Jumlah Rumah pemakai SPAL 9 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

3 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
3 0
0 0
0 0
9 3
0 0
0 0
0 0
0 0
0 0

8 3
0 0
0 0
0 0
1 0
0 0
0 0
0 0
0 0

9 3
9 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 1 1
2 Kumulatif s.d. bulan ini 3 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 3
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 2
2 Jumlah Rumah pemakai SPAL 0 2
 ..................., ............................
Pelapor

.........................................................
 17-3-21
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 2
2 Kumulatif s.d. bulan ini 3 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum 3
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 2
2 Jumlah Rumah pemakai SPAL 2
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 2
0 2
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 11 0
2 Kumulatif s.d. bulan ini 14 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 11 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 3 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 11 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 1 0
Rumah pemakai 11 0
4 Lain-lain 0 0
Rumah pemakai 11 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 11
2 Kumulatif s.d. bulan ini 14 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai
2 SPT
0 KK pemakai 11
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum 3
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 11
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan 1
0 Rumah pemakai 11
4 Lain-lain
0 Rumah pemakai 11
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

11 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 2
0 0
0 0
0 0

0 0
0 0
0 0
11 0
0 0
0 0
0 0
0 0
3 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

11 0
0 0
0 0
0 0
1 0
11 0
0 0
11 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 0 0
2 Kumulatif s.d. bulan ini 14 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini
2 Kumulatif s.d. bulan ini 14 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 2
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 2 0
2 Kumulatif s.d. bulan ini 16 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 2 0
KK pemakai 10 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 8 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 1 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 9 0
2 Jumlah Rumah pemakai SPAL 9 0
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 2
2 Kumulatif s.d. bulan ini 16 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 2
0 KK pemakai 10
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 8
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan 1
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 9
2 Jumlah Rumah pemakai SPAL 9
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

2 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 16 2
0 0
0 0
0 0

2 0
10 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

8 0
0 0
0 0
0 0
1 0
0 0
0 0
0 0
0 0

9 0
9 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 3 0
2 Kumulatif s.d. bulan ini 19 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 3 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 36 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
 9/7/2021
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 3
2 Kumulatif s.d. bulan ini 19 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 3
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum 36
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

3 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 2
0 0
0 0
0 0

3 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
36 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 1 0
2 Kumulatif s.d. bulan ini 20 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 36 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 12 0
Rumah pemakai 12 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 12 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
 17-8-21
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 1
2 Kumulatif s.d. bulan ini 20 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum 36
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 12
0 Rumah pemakai 12
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 12
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 20 2
0 0
0 0
0 0

4 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
36 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

12 0
12 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

12 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 3 0
2 Kumulatif s.d. bulan ini 23 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
 13-9-21
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 3
2 Kumulatif s.d. bulan ini 23 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

3 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 2
0 0
0 0
0 0

4 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 0 0
2 Kumulatif s.d. bulan ini 23 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 0 0
KK pemakai 0 4
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 0 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini
2 Kumulatif s.d. bulan ini 23 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali
0 KK pemakai 4
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 2
0 0
0 0
0 0

0 0
0 4
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 1 0
2 Kumulatif s.d. bulan ini 24 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 5 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 88 0
Rumah pemakai 88 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 2 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 90 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
 24-11-21
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini 1
2 Kumulatif s.d. bulan ini 24 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 5
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 88
0 Rumah pemakai 88
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan 2
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai 90
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 2
0 0
0 0
0 0

5 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

88 0
88 0
0 0
0 0
2 0
0 0
0 0
90 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : Kawalelo
Bulan : Desember 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 0 0
2 Kumulatif s.d. bulan ini 24 2
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4 0
KK pemakai 0 0
2 SPT 0 0
KK pemakai 0 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 0 0
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 0 0
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 0 0
Rumah pemakai 0 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 2 0
Rumah pemakai 0 0
4 Lain-lain 0 0
Rumah pemakai 0 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 0 0
2 Jumlah Rumah pemakai SPAL 0 0
 ..................., ............................
Pelapor

.........................................................
 ###
N0 Elemen Data
L P
I Total Kunjungan Inspeksi :
1 Bulan ini
2 Kumulatif s.d. bulan ini 24 2
0 0
II Klasifikasi Rumah :
0 0
III Jenis SAB :
1 Jumlah Sumur gali 4
0 KK pemakai
2 SPT
0 KK pemakai
3 PAH
0 KK pemakai
4 PMA
0 KK pemakai
5 Hidran umum
0 KK pemakai
6 PP (Captering)
0 KK pemakai
7 Sambungan rumah perpipaan
0 KK pemakai
8 Air Kemasan
0 KK pemakai
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa
0 Rumah pemakai
2 Jumlah Jaga Cemplung
0 Rumah pemakai
3 Jumlah Jaga Plengsengan 2
0 Rumah pemakai
4 Lain-lain
0 Rumah pemakai
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL
2 Jumlah Rumah pemakai SPAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
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0 0
0 0
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0 0
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0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
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0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
L P L P L P L P L P L P L P L P L P L P L

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
P L P L P L P L P L P L P L P L P L P L P

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total
L P L P L P L P L P L P L P L P

0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 2
0 0
0 0
0 0

4 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
2 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 LAPORAN BULANAN
REKAPITULASI KEGIATAN IS TATANAN RUMAH TANGGA II
Desa : ………………….
Bulan : …………………………….. 2021

No. ELEMEN DATA Memenuhi Syarat

Ya Tdk
I Total Kunjungan Inspeksi :
1 Bulan ini 24 2
2 Kumulatif s.d. bulan ini 183 20
0 0
II Klasifikasi Rumah : 0 0
0 0
III Jenis SAB :
1 Jumlah Sumur gali 22 0
KK pemakai 10 4
2 SPT 0 0
KK pemakai 11 0
3 PAH 0 0
KK pemakai 0 0
4 PMA 0 0
KK pemakai 0 0
5 Hidran umum 78 3
KK pemakai 0 0
6 PP (Captering) 0 0
KK pemakai 9 3
7 Sambungan rumah perpipaan 0 0
KK pemakai 0 0
8 Air Kemasan 0 0
KK pemakai 0 0
0 0
IV Jenis JAGA :
1 Jumlah Jaga Leher angsa 127 3
Rumah pemakai 100 0
2 Jumlah Jaga Cemplung 0 0
Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 7 0
Rumah pemakai 11 0
4 Lain-lain 0 0
Rumah pemakai 101 0
0 0
VII SPAL Diperiksa :
1 Jumlah SPAL 30 5
2 Jumlah Rumah pemakai SPAL 18 5
 ..................., ............................
Pelapor

.........................................................
N0 Elemen Data
L P
I Total Kunjungan Inspeksi : 0 0
1 Bulan ini 24 2
2 Kumulatif s.d. bulan ini 183 20
0 0 0 0
II Klasifikasi Rumah : 0 0
0 0 0 0
III Jenis SAB : 0 0
1 Jumlah Sumur gali 22 0
0 KK pemakai 10 4
2 SPT 0 0
0 KK pemakai 11 0
3 PAH 0 0
0 KK pemakai 0 0
4 PMA 0 0
0 KK pemakai 0 0
5 Hidran umum 78 3
0 KK pemakai 0 0
6 PP (Captering) 0 0
0 KK pemakai 9 3
7 Sambungan rumah perpipaan 0 0
0 KK pemakai 0 0
8 Air Kemasan 0 0
0 KK pemakai 0 0
0 0 0 0
IV Jenis JAGA : 0 0
1 Jumlah Jaga Leher angsa 127 3
0 Rumah pemakai 100 0
2 Jumlah Jaga Cemplung 0 0
0 Rumah pemakai 0 0
3 Jumlah Jaga Plengsengan 7 0
0 Rumah pemakai 11 0
4 Lain-lain 0 0
0 Rumah pemakai 101 0
0 0 0 0
VII SPAL Diperiksa : 0 0
1 Jumlah SPAL 30 5
2 Jumlah Rumah pemakai SPAL 18 5
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
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0 0 0 0
0 0 0 0
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0 0 0 0
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0 0 0 0
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L P L P L P L P L P L P L P L P L P L P L
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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