Laserfiche WebLink
PQ„!N SAN JOAQUIN COUNTY <br /> �o. .coG 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 /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: Q:1 <-r'J PR#: <br /> LOCATION: MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: ❑ Single Family Dwelling [&Mobile Home ❑ Other: <br /> #Employees in Unit: -2 Date Unit First Built or Installed: 10 <br /> Electrical Power Provided By: Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. kay <br /> ❑ N eds Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). U50El kay <br /> N eds Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. kay <br /> ElNeeds Repair* <br /> All rooms are clean and sanitary. No insect/rodent infestations present. E[S)kay <br /> ElNeeds Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly Vpkay <br /> vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke detectors are present and tested to be shown in working order. kay <br /> ❑ Ngeds Repair* <br /> All wiring in safe,working order(no splices,exposed wires, uncovered outlets). L30kay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks, properly maintained). kay <br /> ❑ Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <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. [ eeds Repair* 17— <br /> Exterior <br /> ZExterior Checklist Comments <br /> Roof is properly maintained with no holes, loose shingles,leaks,etc. kay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint, holes,etc. 2JOkay <br /> AbNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> eeds Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ElNeeds Repair* <br /> The trash cans are sufficient in size, have lids and are picked up weekly. ETQkay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. kay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. i <br /> ElNeedsds Repair* <br /> air* <br /> There are no insect or rodent infestations. okay <br /> ❑ Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ElNeeds 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: �r.-A C Q— 71 ,q jiq MrjV�'-C�— <br /> NAME DATE TITLE <br /> EH 27-XX 912 012 01 3 Dairy Farm Employee Housing <br />