Laserfiche WebLink
S A N 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 /> OMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: � PR#: <br /> LOCATION: AP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: f <br /> Type of Housing Unit: WSingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: ( Gas Provided by: N WIT <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑ eeds Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. )okay <br /> ❑Needs Re air* <br /> Heater maintained in functioning and safe manner(No space/poltabie heaters), Oka <br /> ❑Needs air* <br /> Doors and windows are accessible/operable to allow for safe exiting. WOkay ElNeeds air* <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 KOkay <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 workinq order. ❑Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Need kay air* <br /> All plumbing in safe,working order(no leaks,properly maintained), Way <br /> ❑Needs Re air* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. El Need ay Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ROkay <br /> no water leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior Checklist 2?6 _ 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. UbkEl Needs Repay air` <br /> Stairways are safe with no rotting,deteriorating,or loose parts, Wkay <br /> ❑Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. MOkEl Needs Repay air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. lQokay <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, Q6kay <br /> ❑Needs Repair* <br /> There are no insect or rodent infestations, Wkay <br /> ❑Nees Repair* <br /> The sewage system Is functioning,with no surfacing wastewater or backup, ❑Needs EyokRepay air" <br /> *Needs R :Pleasespecify dat A e airs tVle completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t4i 61 44ve Inspected the a/bve no nit and that the information provided is true and correct to the best of my knowledge, <br /> SIGNED: r,- <br /> DATE / TITLE <br /> 8 E. Hazeiton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />