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N N <br /> SAN.J OAH I N Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> OUNTYGreatness groes here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> AmuTY NAME' ,orper: <br /> LOCATION: UJ, �O L MAP DESIGNATION: <br /> ."29W G UNIT INFORMATI <br /> /.ddress or identification number of unit '°j u�C� Date of Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> i=iectrical Power Provided By: Gas Provided by: <br /> 11G ISING UNIT INSPECTION <br /> j Ir 4erior Checklist Comments <br /> Unit has hot and cold running water. okay <br /> _ ❑N22dA Repair' <br /> ,'.pproved electrical power and gas fuel being supplied to Unit. 901(ay <br /> ❑Needs a ir* <br /> .heater maintained in functioning and safe manner(No spacelportable Wkay <br /> Boaters). ❑Need Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. ❑N e air• <br /> All rooms are dean and sanitary.No insect/rodent infestations present. kay <br /> ❑Need <br /> Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Mkay <br /> property vented,strapped and are maintained in a safe,working order. ❑Needs)Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown y <br /> in working order. ['.Need Repair' <br /> /,II wiring in safe,working order(no splices,exposed wires,uncovered outlets). L20kay <br /> ❑Need Repair* <br /> Al plumbing in safe,working order(no leaks,properly maintained). [IN kRepair* <br /> Ji counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Need a air° <br /> All floors,walls,ceilings are free from holes,are not sagging or budding,have Mkay <br /> no water leaks and are dean and in good condition. ❑Needs Repair <br /> Eirterior Checklist A Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. y <br /> ❑Needir Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. y <br /> ❑NeeqgR air' <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑N Re air* <br /> propane tank has barrier protection and'No Smoking'signage. Okay <br /> ❑N Repair* <br /> he trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> L,N Re air' <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ <br /> Neeos Repair' <br /> The gas fuel connection is as approved and safe. ElOkRe air• <br /> There are no insect or rodent infestations. ay <br /> ❑N Re ir* <br /> The sewage system is functioning,with no surfacing wastewater or backup. y <br /> ❑Needs Repair* <br /> `Needs Repair.Plejm specify data repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I cern that I have ln&Gted the above noted unit and that the Information Provided Is true and correct to the best of my krfowl <br /> SIGNED <br /> BY: egg 1 Z - s- 19 <br /> NAME DATE TRLE <br /> 1841L H It n Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sicehd.com <br />