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PgUlly SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> IY. Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> 4.`,11��o RrNy`"r <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: 4� f>el,?.,P A, PR#: <br /> LOCATION: 3 7 k / (Y f/d�' �O GA CJ;�Y AP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: # 7 Date of Inspection: 42 <br /> Type of Housing Unit: Ec Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed.- <br /> Electrical <br /> nstalled:Electrical Power Provided By: P Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. k10kay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ©Okay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ©Okay <br /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. 40kay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. l20kay <br /> ❑ Needs Repair <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, WOkay <br /> 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 in working ®Okay <br /> order. ❑ Needs Repair" <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). POkay <br /> ❑ Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). ©Okay <br /> ❑ Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ©Okay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water ©Okay <br /> leaks and are clean and in good condition. ❑ Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ®Okay <br /> _ ❑ Needs Repair' <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. El Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. (Okay <br /> ❑Needs Repair* <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. ®Okay <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 /> ❑ Needs Repair* <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 /> ❑Needs Repair* <br /> `Needs Repair: Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I cerl:4 that I have inspected the above noted unit and that the information provided <br /> /is true//and correct to the best of m knowledge. <br /> SIGNED BY: 111� — U —.2 <br /> NAME DATE TITLE <br /> EH 27-XX 9/20/2013 <br /> Dairy Farm Employee Housing <br />