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00 <br /> AN JOAOUIN Environmental Health Department <br /> COUNTY— <br /> rvoinCss criws here. <br /> DAIRY FARM Emro..OYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> 19 J41t i G S PR#: <br /> LV, �i " � MAP DESIGNATION: <br /> -.�-`MATION <br /> number of unit: Date of Inspection: <br /> .4 .Iou.c,' U .. ❑Single Family Dwelling Mobil Home 0 Other: <br /> Date Unit First Built or Installed: <br /> . T-6;A By: r/ e— Gas Provided by: <br /> X "Ire"11 r4r- .Y^ATION <br /> Comments <br /> QOkV <br /> 1 it has hot anc A r rxang water. L Need$,Hepair* <br /> - MCIk2y <br /> I and gas fuel being supplied to Unit. D Neecli Repair' <br /> tater and safe manner(No spacelponable EjOkay <br /> [I Needs pair* <br /> [Wkay <br /> -wessible/operable to allow for safe exfting. El NeedpAepair* <br /> ROkay <br /> moms are cle?-i an.,sanitary.No insect/rodent infestations present. ❑NeedsRepair' <br /> appliarn. --pr heaters,air conditioning units,heaters)are 06kay <br /> ,v;!y ;nt- -id are maintained in a safe,working order. ❑Needs pair* <br /> r smoke anjou, j 1 i.--noAide detectors are present and tested to be shown 06kay/ <br /> 0 NeedsXepair* <br /> [30kay <br /> j.',0rrrt ir?c-J-: ,'or-i nrder(no splices,exposed wires,uncovered outlets). [] <br /> NeedoRepair* <br /> .,i plumbiro,;irt- girder(no leaks,properly maintained). M0 <br /> ❑N=Yepair' <br /> ;.ts,showers are working and in sanitary condition. iff0ka <br /> E, Aeads a air- <br /> 1:fky.7r,vill r --1re free from holes,are not sagging or buckling,have y <br /> trdlet iecjr- - e c.ean and in good condition. ❑Needs Repair' <br /> Comments <br /> E&1 <br /> J)of Is properly-;Int: +Arith no holes,loose shingles,leakay <br /> s,etc. F1 Needvkepair <br /> edxR <br /> with no loose plaster,peeling paint,holes,etc. [I Neepair' <br /> [Ejka <br /> .�'airwa-jG-- --)tfing,deteriorating,or loose parts. O <br /> 0 Need;7epai <br /> t):op?".tank hw rww protection and'No Smoking'signage. [I Nep�yly <br /> ectw epair* <br /> Q13ka <br /> 'j <br /> size,have lids and are picked up weekly. A]Ne4ed7epaii <br /> DO <br /> !'heelectim!., r..:_ --emd and protected from tampering. M <br /> E4[]Need ka a air* <br /> rhe gas iu,:. as approved and safe. [I Need ir- <br /> epp <br /> Wka <br /> '"here ov,— r,.--Ijpnt infestations. [3 <br /> Need:te;)air* <br /> Cd6kay <br /> t <br /> ioning,with no surfacing wastewater or backup. ❑Needs Repair* I <br /> -pair.PIeW specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finsled. <br /> the above noted unit and that the Information proved Is true and correct to the best Of my knmdGdgO- <br /> 'ei <br /> plv: <br /> NAME 15ATE TME <br /> P i!7,ze n Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjoehd.com <br />