Laserfiche WebLink
SAN .IOAQUIN COUNTY <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> z y <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> N. '• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd JUL 3 0 2014 <br /> DAIRY FARM EMPLOYEE HOUSING ENVIRONMENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLPgyMITISERVICES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: a \ PR#: <br /> LOCATION: t-(t l 0- Al rv� o e1 4 ' i MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION 710 <br /> Address or identification number of unit: bate of Inspection: <br /> Type of Housing Unit: Wingle Family Dwelling Mobile Home❑ D plex❑ Dormitory ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: 1' �r Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ZOkay <br /> _ ❑ <br /> Neep Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. okay <br /> --- O❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). IZ]Okay ---.- <br /> ❑ Nee Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. [1 Needs <br /> Repair* <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 properly v6kay <br /> vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* <br /> All smoke detectors are present and tested to be shown in working order. okay <br /> ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires, uncovered outlets). okay <br /> _❑ Nee Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). 00kay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay <br /> - -- El Needs Re air <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling, have Okay <br /> no water 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 kay _--comments <br /> ❑ Needs Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint, holes,etc. kay <br /> ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ❑ Nees Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. 00kay - -- <br /> ❑ Neects Repair* <br /> The trash cans are sufficient in size, have lids and are picked up weekly. okay <br /> ❑ Neeos Repair* <br /> The electrical panel is covered and protected from tampering. okay <br /> ❑ Neeos Repair* <br /> The gas fuel connection is as approved and safe. okay - — <br /> _. ❑ eeds Repair* <br /> There are no insect or rodent infestations. O ay <br /> ElNee Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Re air* <br /> *Needs Repair: Please specify date repairs to be completed. Building permits required for repairs must be obtained and finaled. <br /> I certify that I have inspect d the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED BY: - - — 7 -IG, C � i.1:�r d 5' Yn a <br /> NAME DATE <br /> i TITLE <br /> EH 27-XX 4/271201 <br /> - Dairy Farm Employee Housing <br />