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SAN JOAQMN <br /> EnvironmelaI Health Department <br /> COUNTY <br /> G`r(otness grans ;.c,e. <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: e- Y`C PR#: <br /> LOCATION: 0 VVI(:v t �.C MAP DESIGNATION: <br /> HOUSING UNI'T INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: (316ingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: , <br /> Electrical Power Provided By: Gas Provided by: --6.— <br /> HOUSING UNIT INSPECTION -- — <br /> Interior Checklist Comments <br /> El kay <br /> Unit has hot and cold running water. ❑ Nee Re air" <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑ Need Repair* <br /> Heater maintained in functioning and safe manner(No space/portable E}bkay <br /> heaters). ❑Needs epair' <br /> kay <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑Need ,e air* <br /> kay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Needp Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown ffOkay <br /> in working order. ❑Needp Repair* <br /> Okay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Need a air* <br /> ay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Need Re air* <br /> kay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ NeecliRepair' <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 ChecklistComments <br /> —901/–W- <br /> 0 y <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ElNees Re air' <br /> y"Okay <br /> f Aerior siding is maintahA with no loose plaster,peeling paint,hcles,etc. ❑Needs,Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. El Need ka a air * <br /> Mkay <br /> Propane tank has barrier protection and'No Smoking'signage. ❑Nee I air' <br /> O y <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Need Re air* <br /> a <br /> The electrical panel is covered and protected from tampering. y <br /> p P ❑Nee s Repair* <br /> O ay <br /> The gas fuel connection is as approved and safe. ❑Ne s Repair' <br /> Okay <br /> There are no insect or rodent infestations. ❑ Neeo Repair_ <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ElNeeds Repair* <br /> *Needs Repair: Pleases ecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have inspect d the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED % ! i ' ' , <br /> NAME V DATE TrrLE <br /> 1868`E. Hazelton 0enue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> i <br /> i <br />