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t.. .; SANJ0A0UINp <br /> Environrr�ental Health Department <br /> --COUNTY-- <br /> DAIRY <br /> -COUNTY-- <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: PR#: <br /> LOCATION: 11+5 MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: k� <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: (�(� <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> ay <br /> Unit has hot and cold running water. eRepair❑ ads <br /> Needs Re air* <br /> Approved electrical power and gas fuel being supplied to Unit. okay <br /> ❑Nee Repair <br /> Heater maintained in functioning and safe manner(No space/portable heaters). SOkay <br /> ❑ Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting. okay <br /> ❑Needs Repair* <br /> All rocros are clean and sanitary,No insect/rodent infestations present. Okay <br /> ❑ e s Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are NOkay <br /> properly vented,stra ed 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). Okay <br /> ❑ Nees Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay <br /> E]Needs Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have NOkay <br /> no water leaks and are clean and in good condition. ❑Nee-A Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. okay <br /> ❑ Nee Re air* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. QOkay <br /> E]Neeads Repair` <br /> Stairways are safe with no rotting,deteriorating,or loose parts. Okay <br /> ❑ Nees Repair* <br /> Propane tank has barrier protection and"No Smoking"signage. Okay <br /> El Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. okay <br /> ❑Nees Repair* . <br /> The electrical panel is covered and protected from tampering. k <br /> ❑Need RR <br /> e air* <br /> The gas fuel connection is as approved and safe. okay <br /> ❑Nee <br /> Repair* <br /> There are no insect or rodent infestations. EJ Need kay Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. Okay <br /> ❑Neebs Re air* <br /> *Needs Re air: leasespecify date repors to be completed.Any Building Permits required for repairs must be obtained and finaled. <br /> I certify t a s ted th bo noted unit and that the information provided is truq and correct to the best of my knowledge. <br /> SIGNED: <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />