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N N <br /> ,.e <br /> SARJOAHIN Environmental Health Department <br /> COUNTY— <br /> Greatness <br /> OUNTYGreatness grows here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILIno,NAME: (y , rG PR#: <br /> • LOCATION' l!! 57 U-1MAP DESIGNATION' <br /> HOUSING UNIT I M F RMATION <br /> Address or ide^fifiication number of unit:l �(,q)0 Date of Inspection: <br /> Type of Housing Unit: ❑Single Family Dwelling Mobile Homr-` ❑Other. <br /> #Employees in Unit: 1_ Date Unit First Built or Installed: <br /> Electrical Pave°er Provided By: Gas Provided by: <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. <br /> ❑ <br /> Needp Repair* <br /> Approved electdca!power and gas fuel being supplied to Unit. []NeedkRe air <br /> Heater maintained in functioning and safe manner(No spacelportable kay <br /> heaters. ❑Needrepair' <br /> Moors and windows are accessible/operable to allow for safe exiting. ay <br /> ❑Need a air• <br /> All rooms are clear,and sanitary.No insect/rodent infestations present. kay <br /> ❑N Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are MOkay <br /> roperly vented,strapped and are maintained in a safe,working order. L_i4e Repair' <br /> Al smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in working order. ❑Needp Repair' <br /> i A wiring in safe,working order(no splices,exposed wires,uncovered outlets). 010kay <br /> ❑N e ir• <br /> Al plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑ ale <br /> it counters,sinks,toilets,tubs,showers are working and in sanitary condition. 0kay <br /> ❑N9951g Repair- <br /> All floors,walls,ceilings are free from holes,are not sagging or budding,have Okay <br /> no water leaks and are dean and in good condition. [I Needs Repair' <br /> artedor Checklist Comments <br /> Roof is property maintained with no holes,loose shingles,leaks,etc. EOk2y <br /> ❑Ngo§Repair' <br /> xterior siding is maintained with no loose plaster,peelinaint,holes,etc. Okay <br /> _ g p ❑Need a air" <br /> L90Stairways are safe with no rotting,deteriorating,or loose parts. kay <br /> _ [1 Need Re air' <br /> Propane tank has barrier protection and'No Smoking'signage. kay <br /> E]Need Re airy <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑N Repair' <br /> I The electrical panel is covered and protected from tampering. ❑Need kRe air* <br /> The gas fuel connection is as approved and safe. ay <br /> ❑Need air` <br /> There are no insect or rodent infestations. ka <br /> [I Need a air• <br /> The sewage system is functioning,with no surfacing wastewater or backup. LjOkay <br /> ❑Needs Repair* <br /> *Needs Repair.Pleasp specify data repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t I have ins265the above noted unit and that the k domration provided Is true and connect to the best of my knowledge. <br /> SIGNED <br /> BY: <br /> NAIiE DwTE TME <br /> 1 . Hazelto venue I Stockton, Califomia 95205 1 f 209 468-3420 1 F 209 464-0138 1 www.SjCehd.com <br />