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SAN JQQQ MN Environmellal Health Department <br /> - COUNTY <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: ro w PR#: <br /> LOCATION: r C � MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION ' <br /> Address or identification number of unit:,-,)5v, (r LVte of Inspection: ) <br /> Type of Housing Unit: ❑ Single Family Dwelling 5Mobile l4orne ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: � Gas Provided by: <br /> HOUSING UNIT INSPECTION _ <br /> Interior Checklist Comments <br /> kay <br /> Unit has hot and cold running water. ❑ Need Repair* <br /> kay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑ Need a air* <br /> Heater maintained in functioning and safe manner(No space/portable Okay <br /> heaters). ❑ Need Repair* <br /> [20kay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Need a air* <br /> • kay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑Need a air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ka <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Need epair* <br /> All smoke and carbon monoxide detectors are present and tested to be shownOkay <br /> in working order. ❑ Need epair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑Need a air* <br /> kay <br /> All plumbing in safe,working order(no leaks,properly maintained). 1:1Nee 'Re air* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Nee a 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 /> ky <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Nee Re air* <br /> kay <br /> Extedor siding Is maintained with no loose plaster,peeling paint,holes,etc. ❑Nee Re air* <br /> Ok <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Need a air* <br /> kay <br /> Propane tank has barrier protection and'No Smoking"signage. ❑Nee Re air* <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Nee Re air* <br /> Okay <br /> The electrical panel is covered and protected from tampering. ❑Nee Re air' <br /> O y <br /> The gas fuel connection is as approved and safe. ❑Nee Re ir* <br /> O <br /> There are no insect or rodent infestations. ❑ Nee Re air* <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Okay <br /> ayair* <br /> *Needs Repair:Ple se specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify thi t I have in cted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED i� r / <br /> AME DATE TITLE <br /> 18! ,E. Hazelt n Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />