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SAN JOAQUIN COUNTY <br /> AqutN. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> F. Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �•. � .•,fie• <br /> 4�iFOR� DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> / C COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: C�5 G�� L L -7 /�vl PR#: ^� <br /> LOCATION: L-G Z (-If X MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: a� <br /> Type of Housing Unit: ❑ Single Family Dwelling ,Q Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: /�� C Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑ eeds Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. i OR <br /> k <br /> ❑Needs Re air' <br /> He,3ter maintained in functioning and safe manner(No space/portable heaters). EJOkay <br /> ElNeeds Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. [IOkay eeds Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. okay <br /> E] N_eeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 60kay <br /> 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 in working E]Okay <br /> order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). El Needs <br /> Needs Re air' <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water 20kay <br /> leaks and are clean and in good condition. ❑Needs Repair' <br /> Erterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ eeds Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Weeds eey <br /> ❑ ds Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. F-1 Okay <br /> eeds Repair* <br /> ay <br /> Propane tank has barrier protection and'No Smoking"signage. l <br /> ❑Needs Repair*e air" <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ElNeeds Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe. [INeeeedskRey air' <br /> There are no insect or rodent infestations. ❑Nee[30kay <br /> Needs Re air' <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑Needs Repair* <br /> *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> l <br /> SIGNED BY: <br /> NAME DATE TITLE <br /> EH 27-XX 9/20!2013 — Dairy Farm Employee Housing <br />