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SANJOAU N Environme'Ral Health Department <br /> Q <br /> —COUNTY- <br /> -fitness fro es her.. <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: PR#: <br /> LOCATION: CMAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of uniate of Inspection: <br /> Type of Housing Unit: ❑ Sin le Family Dwelling 2-mobole H me ❑ Other: <br /> #Employees in Unit: - Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: ;�% f- <br /> HOUSING UNIT INSPECTION <br /> --�- <br /> Interior Checklist Comments <br /> ka <br /> Unit has hot and cold running water. ElNeed a air* <br /> Approved electrical power and gas fuel being supplied to Unit. Elkay eeds air* <br /> Heater maintained in functioning and safe manner(No space/portable kay <br /> heaters). <br /> E-1NeedsRspair* <br /> kay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Nee a air* <br /> Oka - <br /> AII rooms are clean and sanitary.No insect/rodent infestations present. ❑Need a air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ' kay <br /> property vented,strapped and are maintained in a safe,working order. E]Need 'repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okpy <br /> in working order. ❑Neeog Repair* <br /> O y <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Nee Repair* <br /> ri O y <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Nee 5 Re air* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. El Need , e air* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have 90kay <br /> no water leaks and are clean and in good condition. ❑Needs Repair* <br /> Exterior ChecklistComments <br /> Ok y <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑ Need a air* <br /> Exteror siding is maintained with no loose piaster,peeling pai.,t,hdm,etc. k y <br /> ❑ Need epair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. p Nee Re air* <br /> Edo y <br /> Propane tank has barrier protection and'No Smoking'signage. ❑Nee Re air* <br /> Oko <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Nee Re air* <br /> f Okay <br /> The electrical panel is covered and protected from tampering. ❑Need Repair* <br /> uo <br /> The gas fuel connection is as approved and safe. ❑ Nee R air* <br /> ` Ok <br /> There are no insect or rodent infestations. ❑ Nee Re air* <br /> kay <br /> The sewage system is functioningV11ith no surfacing wastewater or backup. ❑ Needs Repair* <br /> *Needs Repair:Phase specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t t I have iospected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: _ TrrLE <br /> NAME DATE <br /> 1> E. Haz ton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />