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SAN J0Q d% Environmental Health Department <br /> COUNTY <br /> _ Greotness 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: y.i - �RrbspAtJ PR#: <br /> LOCATION: l�JQ 4 y'r. n! 6u L fSjLC' MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: I kAjLL•— Date of Inspection: W z-0 <br /> Type of Housing Unit: ❑ Single Family Dwelling [�OMobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: i llo s ? <br /> Electrical Power Provided By: F6 Gas Provided by: <br /> HOUSING UNIT INSPECTION <br /> Interior Cflecklist Comments <br /> Unit has hot and cold running water. Okay <br /> ❑Needs Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. C§Okay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable ®okay <br /> heaters). ❑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. CWOkay <br /> ❑ Needs 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. ❑ Needs Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Okay <br /> in working order. ❑ Needs Repair* <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). okay <br /> E] Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). okay <br /> ❑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 MOkay <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. [Rbkay <br /> ❑ Needs Repair* <br /> Exterior sidingis maintained with no loose plaster,peeling MOkay <br /> p p g paint,holes,etc. ❑ Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑okayi. // , I. <br /> Needs Repair* �/4 57inn5 7c- fl&� T>oe�- 17 r' <br /> Propane tank has barrier protection and'No Smoking"signage. E!lIOkay <br /> ❑ Needs Repair* <br /> The trash cans'are sufficient in size,have lids and are picked up weekly. kay <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 Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑ Needs Repair* <br /> *Feeds 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: _ - 7jZ-I�� c,_y,, -fL <br /> a., <br /> NAME DATE TITLE <br /> �L <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />