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SANJ0AQU IN Environmental Health Department --COUNTY-- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: 4 3 D Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By:P Gas Provided by: As, 12f WS.A- HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. JZLOkay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. okay ❑ Nees Repair* Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Repair*_ Doors and windows are accessible/operable to allow for safe exiting, (] Needskayair* All rooms are clean and sanitary.No insect/rodent infestations present. Okay El Nees Repair* All appliances(stove,water heaters,air conditioning units,heaters)are COkay properly vented,strapped and are maintained in a safe,working order, ❑Nees Repair* All smoke and carbon monoxide detectors are present and tested to be shown Okay in working order. ElNee'ds Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Z]Okay ❑Ne-ebs Repair* All plumbing in safe,working order(no leaks,properly maintained). &,Okay ElNeeds Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay ❑NeNs Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have Okay no water leaks and are clean and in good condition, ❑Nee's Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. NOkay ElNeeds Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, SQkRepair*❑Needs Re air* Stairways are safe with no rotting,deteriorating,or loose parts. .[]Okay ❑ Nee2�1s Repair* Propane tank has barrier protection and"No Smoking"signage. L]Okay ❑ Needdss Repair* The trash cans are sufficient in size,have lids and are picked up weekly. {Okay ❑NeeTT11s Re air' . The electrical panel is covered and protected from tampering. okay El Nee Repair* The gas fuel connection is as approved and safe, okay ❑Nee Re air* There are no insect or rodent infestations. Okay ❑Nees Repair* The sewage system is functioning, ith no surfacing waste ter or backup, Okay ❑ Nees Repair* *Needs R r:Pjfje specify d e re irs to be completed.Any Building Permits required for repairs must be obtained and finaled. 1 certify that ectej the ov noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED DATE "TITLE 1868 E, Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com