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SAN JOAQUIN COUNTY <br /> D- <br /> DAIRY <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 /> FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: G!rJ AI7w1 PR#: 6�X-r;?i�� S^ <br /> � g <br /> LOCATION: Int ��V -i 1144 S�' MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: I�Gv�E- Date of Inspection: 7. I f LZj <br /> Type of Housing Unit: ■ Single Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: lew 4 <br /> Electrical Power Provided By: Gas Provided by: *AnfiyS "7w• G <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ®Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> 11Okay <br /> Approved electrical power and gas fuel being supplied to Unit._ ❑Needs Repair* <br /> Okay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Repair* <br /> n0kay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Needs Repair* <br /> kay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑ Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, [I N00kay <br /> ds Repair* <br /> strapped and are maintained in a safe,workingorder. <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working ❑ Needsay <br /> Repair* <br /> order. <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). [INeedskRey air* <br /> Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑ Needs Repair* <br /> ®Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ Needs Repair* <br /> All floors,walls,cellings are free from holes,are not sagging or buckling,have no water [I Needsay <br /> Repair*leaks and are clean and in good condition. <br /> Comments <br /> Exterior Checklist <br /> ®Okay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑ Needs Repair <br /> Okay <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Needs Repair <br /> Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑ Needs Repair <br /> Okay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑Needs Repair* <br /> kay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Repair* <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* <br /> Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Repair* <br /> Okay <br /> There are no insect or rodent infestations. ❑Needs Repair* <br /> ®Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑ 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: <br /> � NAME DATE TITLE <br /> Dairy Farm Employee Housing <br />