1. Form Rm-1 Survei Pemeliharaan Rutin Jalan

FORM RM-1

SURVEI PEMELIHARAAN RUTIN JALAN CATATAN KONDISI DAN HASIL PENGUKURAN

PROVINSI BALAI BESAR/BALAI SATKER PPK  NOMOR RUAS JALAN JALAN  NAMA RUAS RUAS JALAN

 NO

STA $%m) 2,000 1,50 1,00 1,..0 1,.10 1,.05 1,.00 1,65 1,65 1,620 1,600 1,55 1,5' 1,50 1,'00 1,25 1,20 1,110 1,10. 1,00 0,0 0,00 0,.20 0,.00 0,600 0,600 0,600 0,600 0,520 0,50 0,150 0,000 0,000

: : : : : :

JAWA BARAT

-

-

-

-

-

: : : :

5 OKTOBER 2016 CERAH Km: ! " Km: !

MARTA MARTA NEGARA # TURANGGA " SALAK 

POSISI KIRI KANAN -

TANGGAL SURVEI CUACA STATUS JALAN*) SEGMEN JALAN

KATEGORI KATEGORI KERUSAKAN** ) 11. 116 116 11 111 11 11 11 111 11 116 111 111 111 116 116 116 11 116 116 116 116 116 11 1 '.1 .1  '2 ''1 111 11' 11 111 11.

P $m1)

L $m1)

UKURAN***) & $m1) A $m2)

1!60 1!2 2!5 1! 0!6  2  0! '  0!2 0!5 0!15 2!' 2 ' 2  2 2 1  2!5

0!. 0!6 1!' 0! 0!'5  5 1 0! 2 0! 0!15 0!25 0!15 0!5 0!. 0! 0!02 1 0! 0! 1 0! 1

0!01 0!0. 0!0 0!005 0!01 0!005 0!005 0!0' 0!02 0!005 0!06 0!0' 0!05 0!02 0!0' 0!0 0!05 0!01 0!06 0!025 0!0 0!025 0!02 0!01

1!12 0!.2 '!25 1!26 0!21 16 10  0!16 6 '!2 0!0' 0!1125 0!0025 1!15 0!1 2! 0!0  1!6 1!6 1 '!2 2!5

0!0112 0!050 0!1' 0!006' 0!00'. 0!1 0!05 0!12 0!00'2 0!00' 0!12 0!000 0!0056' 0!0005 0!0'5 0!0056 0!12 0!000 0!2 0!0 0!06 0!025 0!06 0!025

1!5 0! '!5  0!' 2

1!5 0!6 0!1 2 0!15 1!5

0!' 0!02 0!02 0!005 0!025 0!001

2!25 0! 0!'5  0!05 '

0!6.5 0!006 0!00. 0!0 0!001125 0!00'

CATATAN *) &88 &8888 $N9J $N9J ; ; N N8< 8<; ;  P9J P9J ; ; P7<=8 P7<=8; ;8 8 K9J K9J ; ; K( K(= =43 43;/ ;/K< K<4 4)) **) L8+4 Hm; B3%; ***) P : P;>; A : L $P?L) L : L3 L3(7 V : V< V<m3 $A?&) & : &m J : Jm+

KETERANGAN KETERANGAN V $m')

J $(+)

'

10

P34 S7-38

44@ $!!)  NIP! 

KATEGORI KERUSAKAN JALAN 1) 100 - Perkerasan 300 - Trooar 110 &3;; =8 =3;4= '10 &3;; =8 =3;4= 111 L(;"(; '11 R34%/%3+8;; P37m%; 112 K37848; 11' 11 115 116 11. 11 11 120

A7 Am(3 J3m( K37%; 43=8 R34% ( R34% 78 K33m%; = T37%3=

1'0 1'1 1'2 1'' 1' 1'5

T;= L=8 P3;4= L(;"(; K37848; A7 Am(3 P37m%; 43737

150 K% 151 K37%; =3;88 152 3+ m(;; 152 P3;7;; ( 15' @8 m(;; 15' S( =3+/ 734% @8 m(;; 160 L8;"8;

210 211 212 21' 21 215 216

00 - .a/( &3;; =8 =3;4= L(;"(; K37848; J3m( R34% ( K33m%; = T37%3=

2'0 T;= =8 =3;4= 2'1 R34% 343m=4 2'2 Am(3/7 250 T;+ 251 R34% 343m=4 252 K3+8;; =37m%; 25' Rm=4 =;>; 260 L8;"8;

''0 T;= =8 =3;4= ''1 L(;/Am(3

!00 " Per#en$ka%an Ja#an 510 P4<% KM HM 511 R% 512 P4<% +8;

&00 " Kea'aan Dar(ra .10 L<;<7   .11 J; 43744=

51' T37+;

.20 K33%;  8;4 .21 Umm

'.0 B34<; '.1 P3+

520 521 522 52' 52 525

'0 K373( '1 I;34 7% '2 I;34 437m(4

5'0 M7% >; 5'1 M7% =@7 5'2 M7% +

'5 L8;"8;

*00 " Ta#(' 610 K378%8 611 E7<8 612 T3737

'50 B<%/U(8; '51 P37(3@; %348;8;

10 11 12 1'

+00 " Dra,nase T;= =8 =3;4= P3;@;%; K37%; 7; &84m(+8 4;m;

Rm("7m( >; P37(+; 34% Rm( 437+; Rm( 7%   Rm( +8; Rm( +8;/(3;%<%  

620 P;; (4 621 R34%"734% 622 M33;@4

.'0 K37%; =<;@8 .'1 Umm .0 L8;"8;

10 11 12 1'

)00 - Sr(k(r J3m(4; T8m(;; %<4<7; P7/78 =@7   O=784 >; 47;

20 21 22 2'

G<7<;"<7<; ' m T8m(;; %<4<7; P7/78 =@7   O=784 >; 47;

0 L8;"8;

'0 &3;; =8 =3;4= '1 P3;@;%; '2 K37%; 7;

6'0 Rm=4 6'1 Rm=4 =;>;

.0 .1 .2 .'

G<7<;"<7<; T37m(4 K37%; %<;47%8 K37%; %3= G<7<;"<7<;

60 B<;%+; (4 61 K3+8;; (4;

0 1 2 '

S7; 87   Sm=+/7;4+; P3;@;%; T3737

650 L8;"8;

5 L8;"8; C44; : *) ;4% %37%; ; (3m 437%= @m %43<78 4373(4 &8m%%; @m %43<78 8;"8; @; @888 @m %<
CONTOH PENGISIAN ORM RM-1 SURVEI PEMELIHARAAN RUTIN JALAN CATATAN KONDISI DAN HASIL PENGUKURAN

PROVINSI BALAI BESAR/BALAI SATKER PPK  NOMOR RUAS JALAN  NAMA RUAS JALAN  NO

1 2 '  5 6 . 

STA $%m) 0 , 050 0 , 10 1 , 000 2 , 200 ' , 000 ' , 00  , 200  , .00

: : : : : :

SUMATERA UTARA BALAI 1 M3@;

POSISI KIRI KANA  N V V V V V V V

V V

KATEGORI KERUSAKAN** ) 111 11. 252 512 5'1 52' 0 '11

TANGGAL SURVEI CUACA STATUS JALAN SEGMEN JALAN

P $m1)

L $m1)

0!50 1!.0 0!0

0!50 0!0 0!20

60!50

0!12

2!60

1!50

UKURAN***) & $m1) A $m2) 0!05 0!0'

0!25 1!5' 0!0

: : : :

1. &33m(37 1 B37D; Km: 00,000 " Km: 5,000

KETERANGAN V $m')

J $(+)

0!01

6 '!6' . 0!05

'!0

 Expantion joint  3=

CATATAN

P34 S7-38 44@ $M<+! S=78@8) 1100'.00

KATEGORI KERUSAKAN JALAN 1) 100 - Perkerasan 300 - Trooar 110 &3;; =8 =3;4= '10 &3;; =8 =3;4= 111 L(;"(; '11 R34%/%3+8;; P37m%; 112 K37848; 11' 11 115 116 11. 11 11 120

A7 Am(3 J3m( K37%; 43=8 R34% ( R34% 78 K33m%; = T37%3=

1'0 1'1 1'2 1'' 1' 1'5

T;= L=8 P3;4= L(;"(; K37848; A7 Am(3 P37m%; 43737

150 K% 151 K37%; =3;88 152 3+ m(;; 152 P3;7;; ( 15' @8 m(;; 15' S( =3+/ 734% @8 m(;; 160 L8;"8;

210 211 212 21' 21 215 216

00 - .a/( &3;; =8 =3;4= L(;"(; K37848; J3m( R34% ( K33m%; = T37%3=

2'0 T;= =8 =3;4= 2'1 R34% 343m=4 2'2 Am(3/7 250 T;+ 251 R34% 343m=4 252 K3+8;; =37m%;

''0 T;= =8 =3;4= ''1 L(;/Am(3

!00 " Per#en$ka%an Ja#an 510 P4<% KM HM 511 R% 512 P4<% +8;

&00 " Kea'aan Dar(ra .10 L<;<7   .11 J; 43744=

51' T37+;

.20 K33%;  8;4 .21 Umm

'.0 B34<; '.1 P3+

520 521 522 52' 52 525

'0 K373( '1 I;34 7% '2 I;34 437m(4

5'0 M7% >; 5'1 M7% =@7 5'2 M7% +

'5 L8;"8;

*00 " Ta#(' 610 K378%8 611 E7<8 612 T3737

'50 B<%/U(8; '51 P37(3@; %348;8;

10 11 12 1'

+00 " Dra,nase T;= =8 =3;4= P3;@;%; K37%; 7; &84m(+8 4;m;

Rm("7m( >; P37(+; 34% Rm( 437+; Rm( 7%   Rm( +8; Rm( +8;/(3;%<%  

620 P;; (4 621 R34%"734% 622 M33;@4

.'0 K37%; =<;@8 .'1 Umm .0 L8;"8;

10 11 12 1'

)00 - Sr(k(r J3m(4; T8m(;; %<4<7; P7/78 =@7   O=784 >; 47;

20 21 22 2'

G<7<;"<7<; ' m T8m(;; %<4<7; P7/78 =@7   O=784 >; 47;

0 L8;"8;

'0 &3;; =8 =3;4= '1 P3;@;%; '2 K37%; 7;

6'0 Rm=4 6'1 Rm=4 =;>;

.0 .1 .2 .'

G<7<;"<7<; T37m(4 K37%; %<;47%8 K37%; %3= G<7<;"<7<;

60 B<;%+; (4 61 K3+8;; (4;

0 1 2 '

S7; 87   Sm=+/7;4+; P3;@;%; T3737

650 L8;"8;

5 L8;"8; C44; : *) ;4% %37%; ; (3m 437%= @m %43<78 4373(4 &8m%%; @m %43<78 8;"8; @; @888 @m %<
25' Rm=4 =;>; 260 L8;"8;