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SAN J OAQ U I N Environmental Health Department <br /> COUNTY <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: owvk't PR#: <br /> LOCATION: qp tfu- t -,n t X 0 rk MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION o. <br /> Address or identification number of unit: G- S (�>�a� Date of Inspection: L L_ I <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: _-___ <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: CT Gas Provided by: <br /> OUSING UNIT INSPECTION _ <br /> Interior Checklist _ Comments <br /> Unit has hot and cold running water. kay <br /> ❑ Neeos Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. Okay <br /> ElNeeds Repair <br /> Heater maintained in functioning and safe manner(No space/portable kay <br /> heaters)._ ❑ Need Repair <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑ NeeP Repair _ <br /> All rooms are clean and sanitary.No insect/rodent infestations present. Okay — <br /> ❑ Need Repair* _ <br /> All appliances(stove,water heaters,air conditioning units,heaters)are ['Okay <br /> properly vented,strapped and are maintained in a safe,working order. ❑ Need Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown [Okay <br /> in working order. ❑ Need Repair` <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑ Need a air* <br /> All plumbing in safe,working order(no leaks,properly maintained). [20kay <br /> _ ❑ <br /> NeecLs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> _ ❑ Nee Repair <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ff0kay <br /> �o water leaks and are clean and in good condition. ❑ Needs Repair* <br /> Exterior Checklist Z Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ Nee Repair <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑ NeeRepair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. E-:1Okay <br /> ❑ Neeo'S Nee' Repair' <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> ❑ Nee5KRepair. <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Nee Repair <br /> The electrical panel is covered and protected from tampering. okay <br /> El Nee Repair` <br /> The gas fuel connection is as approved and safe. Okay <br /> El Need Repair* <br /> There are no insect or rodent infestations. kay <br /> ❑ Neeo Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *Needs Repair Please specify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify that I have ins a ted the above rioted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: _ �� <br /> - <br /> NAME DATE TITLE <br /> 186 Hazelt n Av ue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />