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SAN J QA U i N Environme al Health Department <br /> Q <br /> COUNTY <br /> 0 <br /> C -ntness grog s here. <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: ��� ' `Ci�V C' ( PR#: <br /> LOCATION: Y e-(' l MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: ��p U , �,y��c. r\ L, a e f Inspection: 1 _ <br /> Type of Housing Unit: 21single Family Dwelling ❑ Mobile ome ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: / 2 Gas Provided by: <br /> %i US1114G UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. kay <br /> El Need Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. kpy <br /> E]Needair* <br /> Heater maintained in functioning and safe manner(No space/portable [(Okay <br /> heaters). ❑ Need's Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑Need a air* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. EjOkay <br /> ❑ NeecK Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are 11bkay <br /> propedy vented,strapped and are maintained in a safe,working order. ❑ Need Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in working order. ❑Need epair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay <br /> ❑Need Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ NeeV Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. kay <br /> ❑ Need a air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have kay <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. ❑Nee kae air* <br /> O y <br /> Exterior Siding i3 nidiii alned with no loose piaster,peeling paint,f01e�,2tC. ElNee Re air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑Nee a air' <br /> Propane tank has barrier protection and'No Smoking'signage. Okay <br /> Need a ai <br /> El r* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. kay <br /> ElNee 'Re air* <br /> The electrical panel is covered and protected from tampering. Olay <br /> ❑Nee Repair* <br /> The gas fuel connection is as approved and safe. O y <br /> E] Neeo Repair* <br /> There are no insect or rodent infestations. okay <br /> ❑ Need Repair__ <br /> The sewage system is functioning,withno surfacing wastewater or backup. E30kay <br /> ❑ Needs Repair* <br /> *Nee Repair:Pleas spec' date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t at I have insppbted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: E� L <br /> NAME t DATE TrTLE <br /> 186 E. Hazelto Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> I <br />