Laserfiche WebLink
SAN 10AQUIN Environmental Health Department <br /> —COUNTY <br /> — <br /> Greatness c,wrows here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING U_VIT <br /> FACILITY NAME: rG PR#: <br /> LOCATION: W. IN, MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Uda Date of Inspection: <br /> Type of Housing Unit: JidSingle Family Dwelling ❑Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electricai Power Provided By: Y^ Gas Fiovided ay: <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. okay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. [30kay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable Ptkay <br /> heaters), ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. , Okay <br /> L, lee Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Need2 Repair <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 210kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in workinq order. ❑ Neeo Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> El Neeo Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). El Okay <br /> Neep Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑NeeA Repair <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Okay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Gkay <br /> [-' <br /> Neecis Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. E] NeeOka5rRe air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. EErokay <br /> ❑ Need Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. kay <br /> E]Need Re air' <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> ❑ Nee Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑Nee Re air` <br /> The gas fuel connection is as approved and safe. Okay <br /> ElNee Repair* <br /> mop <br /> There are no insect or rodent infestations. y <br /> ❑ Nee Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> E] Needs Repair* <br /> *Needs Repair:Please specify date repairs to be completed.Any Building Permits required for repairs must be obt6ined and finaled. <br /> I certify that.1 have insDectef the above noted unit and that the in. .mation provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: A le s e- <br /> Vil! <br /> r <br /> AME ATE TITLE <br /> 1868 /lazelton Av u tockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www-sjcehd.com <br />