Laserfiche WebLink
SAN J O A Q U I N Environmental Health Department <br /> COUNTY <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: CA}It /. i �G'G PR#: <br /> LOCATION: y 1 ✓ Jnr !r►1 LDS . 17 ,Z MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> inspection: <br /> Date of Ins <br /> Address or identification number of unit: `/ p <br /> Type of Housing Unit: ©-Single Family Dwelling ❑ Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: /Y' C Gas Provided by: /" -7 <br /> HOUSING UNIT INSPECTION <br /> Comments <br /> Interior Checklistay <br /> Qdis R <br /> Unit has hot and cold running water. Eleds Re air* <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Ni6eds Repair* <br /> [5�Qkay <br /> Heater maintained in functioning and safe manner(No spacelportable heaters). ❑N ds Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. [:1NeedskRey air* <br /> Okay <br /> All rooms are clean and sanitary.No insectlrodent infestations present. E]Needs Repair'.- <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Okay <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 shownEl NWd kay <br /> Repair' <br /> in workingorder. <br /> kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Repair* <br /> kay <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,ceilings are free from holes,are not sagging or buckling,have ElNee�dskay <br /> Repair' <br /> no water leaks and are clean and in good condition. <br /> Comments <br /> Exterior Checklist 12 5k <br /> ay <br /> 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 /> kay <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. ❑Ieds <br /> eds Repair* <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. El Re air* <br /> kay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* <br /> kay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air* <br /> Okay <br /> There are no insect or rodent infestations. ❑Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. kay <br /> ElNeeds Repair* <br /> *Needs Repair:Pleasespecifydate repairs to be completed.An Buildin 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 /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />