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SAN J 0 A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness 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 /> FACILITY NAME: OA S PR#: <br /> LOCATION: I5636 ST Wt(,V L kt, AU..I 4't 9S3ZO MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: /SSSS S%Er%V E6u l Date of Inspection: Z IS IL I <br /> Type of Housing Unit: [X Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: /150 <br /> Electrical Power Provided By: F6 E Gas Provided by: Y_AAiS -)P A—J E <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ®Okay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable MOkay <br /> heaters). <br /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ❑ Needs Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ®Okay <br /> ❑ Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are pOkay <br /> properly 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 [XOkay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). 4t]Okay <br /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). MOkay <br /> - El Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ]Okay <br /> ❑ Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have [NOkay <br /> no water leaks and are clean and in good condition. ❑ Needs Repair` <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. NOkay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ®Okay <br /> -- <br /> El Needs Repair <br /> Stairways are safe with no rotting,deteriorating,or loose parts. okay <br /> ❑ Needs Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. !Okay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Okay <br /> ❑ Needs Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> ❑ Needs Repair* <br /> The gas fuel connection is as approved and safe. ®Okay <br /> ❑ Needs Repair* <br /> There are no insect or rodent infestations. ®Okay <br /> ❑Needs Re air* <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 inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED <br /> BY: cl�lC5a� 2- Ii I LAA- -w� <br /> NAME DATE a <br /> TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />