Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greotness grows here. <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: vu\ %U\,\ S PR#: <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: -(.RA•``jz t\ (:,2kV() Date of Inspection: 7 rS ltc1 <br /> Type of Housing Unit: ❑ Single Family Dwelling M Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: t�tctC 5 <br /> Electrical Power Provided By: �(?.� Gas Provided by: lLrtv�� Izj �,vF <br /> OUSING 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. Okay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable (&Okay <br /> heaters), ❑ Needs Repair* <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. 550kay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are E40kay <br /> properly vented,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 Okay <br /> in working order. ❑Needs Repair' <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ZOkay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). [AOkay <br /> ❑ Neds 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 [Okay <br /> no water 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 Repair* <br /> ay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. BRepair*❑Needs Needs Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑ Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. (00kay <br /> ❑ Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. 1�3Okay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. C90kay <br /> ❑Needs Repair' <br /> The gas fuel connection is as approved and safe. Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. Okay <br /> ❑ Needs Repair- <br /> The <br /> e air*The sewage system is functioning,with no surfacing wastewater or backup. - kay <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 <br /> BY: / n S 1 f <br /> 1 61 G W7_ <br /> NAMEDATE TITLE <br /> 1868 E. Hazelton Ave ue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />