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�0�� SANG OAQU I N Environmental Health Department QiL�" " l —COUNTY- -1 P./_ Greatness grows here. DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: I�Irtqkcljt. 1) PR#: LOCATION: MAP DESIGNATION: HOUSING UNIT INFIORMATION Address or identification number of unit. 0 L.0 A,, pj Date of Inspection: Type of Housing Unit: ❑ Single Family Dwelling CgMobile Home [] Other: #Employees in Unit: I Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: HOUSING KNIT INSPECTION Interlortheckllst Comments Unit has hot and cold running water. kay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit CROkay ❑ Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). [ffOkay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. Okay ❑ Needs Repair* All rooms are dean and sanitary.No insectirodent infestations present. Okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are MtOkay property 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 130kay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ($Okay ❑ Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). ®Okay ❑Needs Re air' All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Effokay ❑Needs Repair* All floors,wails,ceilings are free from holes,are not sagging or buckling,have [$'Okay no water leaks and are dean and in good condition. ❑Needs Repair* Exterior Checkflst Comments Roof is properly maintained with no holes,loose shingles,leaks,eta Okay ❑ Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. okay ❑Needs Repair* Stairways are safe with no rotting,deteriorating,or loose parts. �IOk ElR Needs Repair* Propane tank has barrier protection and'No Smoking'signage. [ R ❑Neeedsds Ray e aiP The trash cans are sufficient in size,have lids and are picked up weekly. ®Okay ❑Needs Repair* The electrical parcel is covered and protected from tampering. Okay ❑Needs Repair* The gas fuel connection is as approved and safe. Needs Re air There are no insect or rodent infestations. kay ❑Needs Repair* The sewage system Is functioning,with no surfacing wastewater or backup. EVOkay ❑ Needs Repair* *Needs-Re0air Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have I the above noted unit and that the information provided is true and correct to/Ithe best of my knowiedge. SIGNED: 1 ow_ DATE Tnie 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com