Laserfiche WebLink
Q"! SAN JOAQUIN COUNTY <br /> 'o '�c ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Y. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <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: (-1-'4- S T` L�w� C L-s� / �ti 0 PR#: O-F 6 "3 <br /> LOCATION: L G ) C l 1411(A)7A4, MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: 3 75-,ArAS7qly6aFe o Inspection: — <br /> Type of Housing Unit: Casingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: 0 Date Unit First Built or Installed: <br /> Electrical Power Provided By: f�C C Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Intirior Checklist ay Comments <br /> Unit has hot and cold running water. kR <br /> ❑Needs Repair* <br /> JaOay <br /> Approved electrical power and gas fuel being supplied to Unit. Beds R <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). )DOkay <br /> ElNeeds Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. 90k <br /> ❑ R Needs Re air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. eOkay <br /> [I Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, E30kay <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 E30kay <br /> order. ❑Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> [INeeds Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑ eeds Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water ,®Okay <br /> leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior Checklist Comments <br /> 130kRoof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs R air' <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. CYeR <br /> El Needs ds Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ®Okay <br /> [INeeds Repair* <br /> ay <br /> Propane tank has barrier protection and*No Smoking"signage. BR <br /> ❑ Needs eds Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> El Repair* <br /> The electrical panel is covered and protected from tampering. ®Okay <br /> ElNeeds Repair* <br /> Th-i gas fuel connection is as approved and safe. Okay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations. ❑Needs <br /> eeds Re air• <br /> The sewage system is functioning,with no surfacing wastewater or backup. eeOkay <br /> ElNeeds Repair* <br /> *Needs Repair: Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> 1 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 /> SIGNED BY: <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 Dairy Farm Employee Housing <br />