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0 - 00 <br /> ,�`+N J OAO U I N Environmental Health Department <br /> ----COUNTY <br /> .c Incss crop,s here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> = <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> �F COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> �Q R fC 5 PR#: <br /> *iAP DESIGNATION' <br /> aoeT number of unit: (pf-tp liate of Inspection: Z <br /> r ^ Single Family Dwelling Q]�Mobile home El Other <br /> _ Date Unit First Built or Installed: <br /> _ By: / Gas Provided by: — <br /> Comments <br /> i,ct.in water. Y <br /> ❑ <br /> _ Need air' <br /> aas fuel being supplied to Unit. ka <br /> _ [INeeds a air <br /> :;ar;rs�•u�ai..a.. ,:,_.:fnq and safe manner(No space/portable 06kay <br /> :'a.ers ❑Needs apair* <br /> I Ir -;,,acsiblel operable to allow for safe exiting. ka <br /> _ El Need a air <br /> Y.No insectlrodent infestations present. kay <br /> _ _ F'4eeds a air <br /> aiers,air conditioning units,heaters)are Delkay <br /> maintained in a safe,working order. ❑NeedsRepair' <br /> +,. . ie detectors are present and tested to be shown Ea6ka <br /> ❑Needs epair* <br /> -� no splices,exposed wires,uncovered outlets). Need EJ&ae air <br /> der(no leaks,properly maintained). [JOk <br /> _ 11 air <br /> i;3,showers are working and in sanitary condition. [91Oka <br /> 11Ne a air' <br /> ,(xe from holes,are not sagging or budding,have Cf0kay <br /> Ar and in condition. ❑Needs Repair <br /> �-- ---- —_ �—_ ---•_-- _ Comments <br /> err• 'r ;�'r no holes,loose shingles,leaks,etc. <br /> _ ❑Need a air• <br /> j; ::,pith no loose plaster,peeling paint,holes,eic. k <br /> _ [I Need a air <br /> - iti.g,deteriorating,or loose parts. y <br /> _ ['t Need a air* <br /> ;.r,. -.r... . action and'No Smoking'signage. y <br /> ❑ Repair- <br /> size, <br /> e air- <br /> size,have lids and are picked up weekly. O y <br /> ❑NeedsR air <br /> c-ed and protected from tampering. O y <br /> 11Re air <br /> �s approved and safe. ay <br /> ❑Nee0s R air* <br /> _. tc arf,o�i�L`,. . a ;��infestations. kA <br /> ❑ O <br /> R air <br /> ;•�- Oiling,with no surfacing wastewater or backup. Okay <br /> ❑Needs Repair* <br /> fodpair Please specify date repairs to be completed.Any Building PermiLg required for repairs must be obtained and finaled. <br /> inspected the above noted unit and flat the information provided Is true and correct to the best of my knowledge. <br /> AME DATE v TLE <br /> zr,7n Avenue I Stockton, Califomia 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />