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S A N_;J 0 A Q U IN Environmental Flealth Department --COUNTY-- h1cotness nroras DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: PR#: LOCATION: 2 MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: Date of Inspection: Z'5- Type of Housing Unit: 59 Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: - CWWVZ&s Provided by: S 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 [INe-e'l Repair ay * _ Heater maintained in functioning and safe manner(No space/portable heaters). ❑ NeedOSkRepair * Doors and windows are accessible/operable to allow for safe exiting, NOkay ❑ Nee air* All rooms are clean and sanitary.No insect/rodent infestations present. NOkay ❑ Nees Repair* All appliances(stove,water heaters,air conditioning units,heaters)are NOkay properlyvented,strapped and are maintained in a safe,working order. ❑Nee21s Repair* All smoke and carbon monoxide detectors are present and tested to be shown Okay In working order. ❑Nee s Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). Okay [:1 Nees Re air* JQ All plumbing in safe,working order(no leaks,properly maintained). El Okay Neelds Repair All counters,sinks,toilets,tubs,showers are working and in sanitary condition. Okay ❑Nees Repair* All floors,walls,ceilings are free from holes,are not sagging or buckling,have COdy kay no water leaks and are clean and in good condition. ❑NeeRepair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay ❑Nee Repair* qOkay Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. p Neelis Repair* Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑ Ne s Repair* Propane tank has barrier protection and"No Smoking"signage. Okay Nee Els Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ElN e Repair* . The electrical panel is covered and protected from tampering, okay _ ❑NeeA Repair* The gas fuel connection is as approved and safe. &Okay ❑Needs Repair- There e air*There are no insect or rodent infestations. Okay ❑Nee Repair* The sewage system is functioning,with no surfacing wastewater or backup. �ay ElNeeds Re air* *Needs Repair:PleaV specify date repairs to b om leted.Any Building Permits required for repairs must be obtained and finaled. I certify that/hin ec d thw-.b9*-,fn.teddWJt and that the information provided is true and correct to the best of my kn wl dge. SIGNED: ATE 1 TITLE 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com