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SA N IJ OA Q U I N �'iffinr 'ental Health Department <br /> COUNTY <br /> _ t �� c� :, LJ�J <br /> Greatness grows here. <br /> BIRO 1:1riLi�JTAL HEALTH <br /> �T/SER10CES <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: cpvTOr ) ,,ks PR#: <br /> LOCATION: llj f0;5 j L1lJ G�7J1 �al C--_<ALiwJ Cit cil'5; LZQ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: •z 115 I <br /> Type of Housing Unit: ❑ Single Family Dwelling [X Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: Igc\O's <br /> Electrical Power Provided By: Gas Provided by: 4,AM S Ra Nd'v.0"e <br /> OUSING 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 (FOkay <br /> heaters), ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. Okay <br /> ElNeeds Repair* <br /> All rooms are clean and sanitary.No insect/rodent infestations present. 5Okay <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). C40kay <br /> ❑Needs Repair' <br /> All plumbing in safe,working order(no leaks,properly maintained). [80kay <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 [SOkay <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. Okay <br /> ❑ Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. (Okay <br /> ❑ Needs Repair- <br /> Propane <br /> e air'Propane tank has barrier protection and"No Smoking"signage. [gOkay <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 /> ElNeeds 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 /> ElNeeds 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: Z I I S 119 <br /> LAJA C jL <br /> NAME DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www-sjcehd.com <br />