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Environmental Health Department <br /> - COUNTY <br /> Greatness groves here. <br /> DAIRY FARM EMPLOYEE HOUSING <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY DAME: lit V PRM <br /> LOCATION: c MAP DESIONmm: <br /> Td <br /> AddrM or klerfAkadon number of un[L 'Tt)A Date of inspection: °,–jSr A0t <br /> Type of Housing Unk ,'Single Family Dwelling ❑mobile Home ®Other. <br /> e Employees in Unit _ Date Unit First t5_ It or Installed: <br /> Elect Power Provided By: Gas Provided by <br /> TI <br /> /ItwffOr ch Ole CQ1BMWItIs <br /> flit has hot and cold nnning waler. ElUkay— <br /> ❑Needs Roper <br /> Approved deckW power and gas fuel being suppled to UniL [I Neeft r <br /> Healer maintained in funclionng and sale farrier(No epsoelpatable <br /> pleaders. Q Needs Repair <br /> Doan and windows are accede/operable to slow for sate eadting. <br /> All rooms are dean and sanitary.No irseflrodent idestaUorts present BMW <br /> All appliances(stove,wafer heaters,air condilif o nirg units.healers)are <br /> reeled,drapped and are m0 twined in a sate,working order. El Finn's Repair <br /> Al smoke and carbon monadde deleciors are present and tested b be shm ERbW <br /> in wmtnp order. ReW <br /> All won in sale,working order(no splices,earposed wires.uncovered outlets). E!rOkay <br /> Al plumbing in sate,working oder(no leaks,properly maintained). ❑Needs RapairO <br /> Al counters,sinks,toilets,tuba,showers are wading and in sanitary wrditim. 0kay <br /> 13 L*m r <br /> Al floors,walls,oelings are free from holes,are not sagging or buckling,have Okay <br /> no water leaks and are dean and in good condition. ❑Needs Repah" <br /> EX edbr rhAcldixt __ _ C019lII►allti <br /> Rod is ppe4 maintairned with ija holes,loose shim,leaks,etc --, - de96 --- — v <br /> r <br /> Exterior siding is maintained with no loose Master,Ping paint,holes,oft. ® r <br /> Staliways are sate wdh no raltUtg,delerforWing,or loose parts. Elnr <br /> Propane tank has bww protection and'No Snaking'signage. n nr <br /> havY <br /> The trash cats are sunkaent in size, e Inde and are picked up weekly. <br /> Theacm paw is wvered and p ram from tafrpm". 151r. y <br /> The gas fuel connection is as approved and safe. <br /> Neep Rein' <br /> Thwe are no Insect or rodent infesWm. RapW <br /> The somp system is functioning,with no surfacing wastewater or bada�. Oka <br /> ®Deeds y 'r <br /> `Needs .Please speCq dais to be completed.ArgrJ'tilding Perr&reguhed for repairs mtmt be obfstted and*WW. t <br /> i tltet Rave bis tits above rioted w*and 60 ft Warnation WmIded Is true and correct to the best of <br /> son <br /> ,e mLr <br /> 1t368 f.fimeftn Avyludio%joelmn, Cal'rfemia 952051 T 209 468-34201 F 209 464-0138 1 www.sjc elxl.cmrn <br />