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SAN J OA Q U I N Environmental Health Department
<br /> —COUNTY-----
<br /> .
<br /> DAIRY FARM EMPLOYEE HOUSING
<br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST
<br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT
<br /> Mill
<br /> FACILITY NAME: { . r�' "�° , PR#:
<br /> LOCATION: , -, I '1 �- �� IM 04 "'LMAP DESIGNATION:
<br /> HOUSING UNIT INFORMATION
<br /> Address or identification number of unit:,- !��. .+
<br /> 7� •,.. Date of Inspection: �� •��
<br /> Type of Housing Unit: ❑Single Family Dwelling ❑ Mobile Home ❑Other:
<br /> #Employees in Unit: ar Date Unit First Built or Installed:
<br /> Electrical Power Provided By: �JG, , 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. -00kay
<br /> ❑Needs Re aiP
<br /> Heater maintained in functioning and safe manner(No space/portable heaters), kay
<br /> ❑ eeds Re air'
<br /> Doors and windows are accessible/operable to allow for safe exiting, okay
<br /> ❑Needs Re air'
<br /> All rooms are clean and sanitary.No Insect/rodent infestations present, Okay
<br /> All appliances(stove,water heaters,air conditioning units,heaters)are ❑NeedOskRepair,
<br /> properly vented,strapped and are maintained in a safe,working order, 11 Neeeds Repair"
<br /> All smoke and carbon monoxide detectors are present and tested to be shown 00kay ---
<br /> in working order. ❑Needs Repair'
<br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ERe
<br /> ❑N
<br /> All plumbing in safe,working order(no leaks,properly maintained),
<br /> N
<br /> All counters,sinks,toilets,tubs,showers are working and In sanitary condition. Qokay
<br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have Needka e air'
<br /> no water leaks and are clean and in good condition. El Needs Repair'
<br /> Exterior Checkllst
<br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay Comments
<br /> ❑Needs Repair*
<br /> Exterior siding Is maintained with no loose plaster,peeling paint,holes,etc, (Okay
<br /> Needs Repair
<br /> Stairways are safe with no rotting,deteriorating,or loose parts. ,I::IOkay
<br /> Needs Re air'
<br /> Propane tank has barrier protection and'No Smoking"signage. Okay
<br /> ❑Needs Repair*
<br /> The trash cans are sufficient in size,have lids and are picked up weekly. 00kay
<br /> ❑Needs Repair* .
<br /> The electrical panel is covered and protected from tampering. ❑Okay
<br /> ❑Needs,Repair*
<br /> The gas fuel connection is as approved and safe. ❑Okay
<br /> --------- ElNeeds Repair*
<br /> There are no Insect or rodent infestations, UOkay
<br /> Needs Repair*
<br /> The sewage system is functioning,with no surfacing wastewater or backup, El Needs L-10kay
<br /> Repair*
<br /> 'Needs Repair Pleasespecify date re airs to be com leted.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 /> DATE Tm.e
<br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 WWW.sjcehd.com
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