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_° `"c�� SAN�JOAQUIN p =� Environmental Health Department COUNTY °_411. 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: ? a. MAP DESIGNATION: HOUSING UNIT INF RMATION Address or identification number of unit0.1.$9 p , A 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: HOUSING UNIT INSPECTION Interior'Checkfist Comments ❑ Unit has hot and cold running water. okay Needs Repair* Approved electrical power and gas fuel being supplied to Unit Okay ElNeeds Repair* Heater maintained in functioning and safe manner(No spacelportable heaters). Okay Needs Re ai [:1r* Doors and windows are accessible/operable to allow for safe exiting. Okay E] Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present. Okay ❑ Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are 510kay propedy vented 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). [90kay ElNeeds Repair* All plumbing in safe,working order(no leaks,properly maintained). Okay ❑ Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay ❑ Needs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have NrOkay no water leaks and are dean and In good condition. ❑ Needs Repair* Exterfor Checkffst Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay ❑Needs Repair' Exterior siding is maintained wif}triofoose plaster,peeling paint,holes,etc. Rokay ElNeeds Repair* Stairways are safe with no rotting,deteriorating,or loose parts. igOkay ❑Needs Repair* Propane tank has barrier protection and'No Smoking'signage. KOkay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑ Needs Re air* The electrical panel is covered and protected from tampering. Okay ❑Needs Repair* The gas fuel connection Is as approved and safe. Okay ❑Needs Repair* There are no insect or rodent infestations. r�jOkay ElNeeds Re air* The sewage system is functioning,with no surfacing wastewater or backup. okay ElNeeds Re air* *Needs Repair Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. 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.1 SIGNED: w.. DATE TMF 1868 E. Hazelton Avenue I Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com