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SAN JOAQ <br /> Environmetal Health Department <br /> N <br /> - COUNTY <br /> Caret3trlc'ss yrc>ass fiere. <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: •J cr, ilAca !21i MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: ('L ci lcu iu r' ate of Inspection: <br /> Type of Housing Unit: [j Ingle Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: _ Date Unit First Built or Installed: <br /> Electrical Power Provided By: r Gas Provided by: <br /> HOUSING UNIT INSPECTION —. <br /> Interior Checklist Comments <br /> kay <br /> Unit has hot and cold running water. El Needs a air* <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 Mokay <br /> heaters). ❑Need Repair* <br /> Lima <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 kay <br /> property 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 shown ETOkay <br /> in working order. ❑ Needs epair* <br /> kay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Need a air* <br /> kay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Need a air* <br /> ko <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑ Need 'fie 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. El Need Ike air* <br /> E>derior siding is maintai,ied with no loose plaster,peeiik yng paint,holes,etc U Need Repair* <br /> i ay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑Nee Repair* <br /> Olay <br /> Propane tank has barrier protection and"No Smoking"signage. ❑NeecV Repair* <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. ❑Need ke air* <br /> IjJ0kay <br /> The gas fuel connection is as approved and safe. ❑ Need 'Repair* <br /> �15k <br /> There are no insect or rodent infestations. ❑ Need a air* <br /> L40kay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Repair* <br /> *N eds Repair:Pleas specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify hat I have insp ted the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: ° �` /r'7 <br /> - - DATE TrrLE <br /> 1861 E. Hazelton, enue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />