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PQ�tN SAN JOAQUIN COUNTY <br /> '� "� ENVIRONMENTAL HEALTH DEPARTMENT <br /> _: 2 <br /> '< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> bog <br /> Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> CP <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: I I r 466 PR#: <br /> LOCATION:,, (,,f MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: ingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: C. <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water, ElNeed kRe air* <br /> Approved electrical power and gas fuel being supplied to Unit. [90kay <br /> ElNee s Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). Okay <br /> [I Nee Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. EjOkay <br /> ❑ NeedE Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are properly vented, ffokay <br /> strapped and are maintained in a safe,working order. ❑ Need epair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown in working Mkay <br /> order. ❑ Need Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). EjOay <br /> ❑ Need kRe air* <br /> All plumbing in safe,working order(no leaks,properly maintained). kay <br /> ❑Nee Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> ❑Needs a air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have no water D6kay <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 /> ❑ Need epair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑Nee09 Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> [:1Nee5a air* <br /> Propane tank has barrier protection and"No Smoking"signage, ElNeeOka a air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee a air' <br /> The electrical panel is covered and protected from tampering. Ok <br /> ❑ Need Re air* <br /> The gas fuel connection is as approved and safe. ElNeed Ll'oka epair* <br /> There are no insect or rodent infestations. Ok y <br /> ElNee Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑Needs 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 a above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: ;'�P <br /> y NAME DATE TITLE <br /> I <br /> EH 27-XX 9/20/2013 . Dairy Farm Employee Housing <br />