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SAN J 0 A Q U I N Environmental Health Department --COUNTY-- G I C,t I —COUNTY--GIC,tI Ss ji'GI'1'i DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CH,FCKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: 2 (D'�A I MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: 111117-5 Type of Housing Unit: q5ingle Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: E rAGas Provided by: W HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water, Okay ❑ Nees Repair" Approved electrical power and gas fuel being supplied to Unit. Okay ❑ Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). Okay [I Nee e Re air* Doors and windows are accessible/operable to allow for safe exiting. El NJ Okay El All rooms are clean and sanitary.No insect/rodent infestations present. okay E] Nee Repair*_ All appliances(stove,water heaters,air conditioning units,heaters)are -p Okay properly vented,strapped and are maintained in a safe,working order. ❑Nee Repair* _ All smoke and carbon monoxide detectors are present and tested to be shown 'ROkay in working order. ❑ NeA Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay ElNe s Repair* All plumbing in safe,working order(no leaks,properly maintained). , Okay Ele s Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay El Nee Re air* All floors,walls,ceilings are free from holes,are not sagging or buckling,have I]Okay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. NOkay ❑ Nee ddss Repair" Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. Okay ❑Ne Repair* Stairways are safe with no rotting,deteriorating,or loose parts. QOkay ❑Needs Repair* Propane tank has barrier protection and"No Smoking"signage. Okay 0 Neetk Repair* The trash cans are sufficient in size,have lids and are picked up weekly, `Okay ❑Neem,Repair* . The electrical panel is covered and protected from tampering. Okay ❑Nee6s Repair" The gas fuel connection is as approved and safe. ElNeeOkRe air* There are no insect or rodent infestations. QOkay ❑Nee'66 Repair* The sewage system Is fun* ning,with o surfacing wastewater or backup. 'QOkR ❑Nee Re air* *Needs r:Ple s eci ate r airs to com feted.Any Building Permits required for repairs must be obtained and finaled. I cern th i e e ab a not nit and that the information provided is true and correct to the best of my knowledge. SIGNED ATE ITL 1868 E, Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com