Laserfiche WebLink
SAN �Q U I N Environmeeee'Pal Health U� :; iartment <br /> Q <br /> COUNTY <br /> Grcntness grows ?ere. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: PR#: <br /> LOCATION: `; Cv\ V\L n 0 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: n: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECT!ON <br /> Interior ChecklistComments <br /> kay <br /> Unit has hot and cold running water. ❑ Needs a air* <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Need!g Repair- <br /> Heater <br /> e air*Heater maintained in functioning and safe manner(No space/portable Okay <br /> heaters). ❑Nee Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑Need Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. kay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 1310kay <br /> property vented,strapped and are maintained in a safe,working order. ElNee Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in working order. ❑ Needp Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E]NeedEjOkRe air* <br /> kay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑NeedprRepair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ElNeed Re air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have kay <br /> no water leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior ChecklistLff Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ElNee s Repair. <br /> Exterior siding is maintained witn no loose plaster,peeling paint,hoies,etc. f°Okay <br /> ❑Nee Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ElNee Re air' <br /> Propane tank has barrier protection and'No Smoking'signage. Okay <br /> E] Nee Re air` <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee s Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑Nee Repair* <br /> The gas fuel connection is as approved and safe. ❑ Nee Re air* <br /> There are no insect or rodent infestations. Ok y <br /> ❑Need Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ❑ Needs Re air' <br /> *Needs Repair: Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify th t I have ins cted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: _ <br /> ' NAME DATE TITLE <br /> 18 E. Hazeltn)/Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sjcehd.com <br />