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SANJOAQUIN Department Environmental Health De --COUNTY-- t_IIGolrIeS5 grnP;_; her'". ®AIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: L_C PR#: LOCATION: L,p MAP DESIGNATION: HOUSING UNIT NFORMATION Address or identification number of unit: Date of Inspection: tl Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: P4�2r Gas Provided by: J S wQ-S HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. ❑Okay ElNeeds Repair* Approved electrical power and gas fuel being supplied to Unit. ❑Okay ElNeeds Repair* Heater maintained in functioning and safe manner(No space/portable heaters), ❑Okay ElNeeds Repair* Doors and windows are accessible/operable to allow for safe exiting. []Okay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present, ❑Okay _ ElNeeds Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ❑Okay properly vented,strapped and are maintained in a safe,working order. ❑ Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown ❑Okay in working order. ❑ Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). E] Needs Needs Re air* All plumbing in safe,working order(no leaks,properly maintained). ❑Okay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition, []Okay ❑Needs 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. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Okay ElNeeds Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ❑Okay ElNeeds Repair* Stairways are safe with no rotting,deteriorating,or loose parts. ❑okay [INeeds Re air* Propane tank has barrier protection and"No Smoking"signage. ❑Okay El Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly, ❑Okay ElNeeds Repair* . The electrical panel is covered and protected from tampering. ❑okay E] Needs Repair* The gas fuel connection is as approved and safe. ❑Okay E]Needs Repair* There are no insect or rodent infestations. ❑okay El Repair* The sewage system is functioning,with no surfacing wastewater or backup. []Okay ElNeeds Repair* *Need/Rair:/lease seci dgte r irs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify a a i spec ed th b e noted unit and that the information provided is tr1je an4 correct to the best f m now ed 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