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pAp•V; ! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> :'• Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> eq`'FORa`p. <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 ;/J EA17,vtS Q41[--j PR#: <br /> LOCATION: ?-ds- e-i tL,✓ c.a. MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: j5(�S S �7C.;�eClvL Date of Inspection: 2,. <br /> itLl(L <br /> Type of Housing Unit: ®Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: <br /> Electrical Power Provided By: C� Gas Provided by: I�S <br /> HOUSING 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. kay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). 5 Okay <br /> ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting, 11190kay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, 590kay <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 i'.Tli Okay <br /> order. <br /> ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑Needs Re air* <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 U Okay <br /> 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. Okay <br /> -— -- ---- --- ❑Needs Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑ N eds Re air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. WOkay <br /> ❑Needs Re air* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑N eds Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. NOkay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. WOkay <br /> ❑ Needs Re air* <br /> The gas fuel connection is as approved and safe. tpOkay <br /> ❑ Needs Re air* <br /> There arEinsect r rodent infestations. [�Ij.Okay <br /> ❑Needs Re air* <br /> The sewas functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *Needs Repair: Please specify 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 /> SIGNED BY: `. IIZS/z- <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 <br />