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SAN J 0 A U U I N Environmental Healt <br /> ` 'i COUNTY <br /> Greotness grows here. FEB 2 3 2018 <br /> DAIRY FARM EMPLOYEE HOUSING ENWROWENTAL HEALTH <br /> ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST PERMIPSERVICES <br /> COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT <br /> FACILITY NAME: V3 c^-VoN PR#: <br /> LOCATION: 1'16S5 rj"i f NKa%:L- (LCI. E (A"PJ C4 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: i r <br /> Type of Housing Unit: ® Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: I Date Unit First Built or Installed: N/A <br /> Electrical Power Provided By: PG 4 E Gas Provided by: KAM PS �0 IV'f(—� <br /> OUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ROkay <br /> ❑ Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. ROkay <br /> ❑ Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable 50kay <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. [e <br /> ❑Needs <br /> Repair* <br /> air` <br /> All appliances(stove,water heaters,air conditioning units,heaters)are [ROkay <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 /> ❑Needs Repair* <br /> All plumbing in safe,working order(no leaks,properly maintained). QOk <br /> ElR 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 [Okay <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 /> E] Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. [UOkay <br /> ElNeeds Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ®okay <br /> ay <br /> Repair* <br /> Propane tank has barrier protection and"No Smoking'signage. k <br /> ❑ R Needs Re air* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ®Okay <br /> ElNeeds 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 /> ElNeeds 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 1 ;Mlt�yi(aC'1Z <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 />