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SAN��QQQUN Environmental Health Department „� U .:_ ` —COUNTY \C9P� Greatness grows here. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: dir tk-I MAP DESIGNATION: HOUSING UNIT INF RMATION Address or identification number of unit:),,Lg 6 r.o��rt,Pj Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling [$Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: QnfpQrg HOUSING UNIT INSPECTION Interlortheckfist Comments Unit has hot and cold running water. ❑ $Okay Needs Repair* Approved electrical power and gas fuel being supplied to Unit Okay EDNeeds Repair* Heater maintained in functioning and safe manner(No space/portable heaters). Okay 171Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. ElNeeeddskRey air* All rooms are d ❑clean and sanitary.No insect/rodent infestations present. ®okay Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ®Okay propropey vented,strapped and are maintained in a safe,working order. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown ®Okay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). [$Okay [INeeds Repair* All plumbing in safe,working order(no leaks,properly maintained). [30kay ❑Needs Repair' All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay R ❑Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have G�Dkay no water leaks and are dean and in good condition. ❑Needs Repair* Exterior ChecWlst Comments Roof Is properly maintained with no holes,loose shingles,leaks,etc. [$Okay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ®Okay ElNeeds Repair* Stairways are safe with no rotting,deteriorating,or loose parts. Okay EDNeeds Re air* Propane tank has barrier protection and'No Smoking'signage. Okay ElNeeds Repair* The trash cans are sufficient in size,have lids and are picked up weekly. IROkay ❑Needs Repair* The electrical panel is covered and protected from tampering. ®Okay ElNeeds Repair* The gas fuel connection is as approved and safe. ®Okay [3Needs Repair* There are no insect or rodent infestations. ❑ eeOkay Needs Repair* The sewage system is functioning,with no surfacing wastewater or backup. ®Okay ElNeeds Repair* *Needs Repair Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I cerft that I have Inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: DATE Tm_E 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com