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� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> \'•. _•J Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.s- <br /> �c; oaN`P sigov.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: !� {c: ' t,'�S <br /> PR#: <br /> LOCATION: !S(4S� �! iryC'(►�'L �. L`ice Lc:^' sa <br /> MAP DESIGNATION: <br /> HOMIN <br /> IT INFORMATION <br /> Adntification number of unit: <br /> I S fS Sie�'�c c t Date of Inspection: I/zy/2Z <br /> Tyg Unit: ❑ Single Family Dwelling ® Mobile Home ❑ Other: <br /> s in Unit: � Date Unit First Built or Installed: wwer Provided B 7 iy�Cy <br /> y' � Gas Provided bHOT INSPECTION Y ��5 �'�i= <br /> Interior Checklist <br /> Unit has hot and cold running water. Comments <br /> [Okay <br /> ❑ Needs Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. ®Okay — <br /> ❑Needs Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ®Okay <br /> ❑ Needs Re air* <br /> Doors and windows are accessible/operable to allow for safe exiting. ®okay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. [NO ay <br /> El All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, Needs ay air* <br /> strapped and are maintained in a safe,workingorder. GtlOkR <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working <br /> Needs Repair* <br /> order. 9 IZOkay <br /> ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). i ]Okay <br /> ❑ Needs Re <br /> All plumbing in safe,working order(no leaks,properly maintained). air* <br /> Okay <br /> ❑ Needs Re air* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. NOkay <br /> All floors,walls,ceilings are free from holes,are not sagging or bu�kr�g,have no water Needs ay air* <br /> 000K <br /> ay and are clean and in good condition. <br /> - --- - <br /> Exterior Checklist ❑Needs Repair* <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ®OkCommentsay <br /> -- - - -- ----- -- Ed Needs-Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ®OkaY <br /> ❑ - - <br /> -- - <br /> - <br /> Needs Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [pOkay <br /> ❑Needs Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Needs Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Needs Re air* <br /> The electrical panel is covered and protected from tampering. [40kay <br /> ❑ Needs Re air* <br /> The gas fuel connection is as approved and safe. WOkay <br /> ❑ Needs Re air* <br /> There are no insect or rodent infestations. [Okay <br /> ❑Needs Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑Needs Re air' <br /> *Needs Repair: Please specify date re airs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I <br /> certify that I have inspected the above noted unit and that the information provided is true and correct to the best of m knowled e. <br /> SIGNED BY: > �� � <br /> _ sbu_ Lw'C7L <br /> NAME <br /> .H 27-XX 9!2012013 DATE TrTLE <br />