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SAN J O A Q U I N Environmental Health Department <br /> - <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: C11S417t - S 77 11 PR#: <br /> LOCATION: `I [Al `'ti '✓I l l �i�� AMA0�ESIMATION: <br /> HOUSING UNIT INFORMATION — <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: Single Family Dwelling ❑ Mobile Home El Other: _— <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: Gas Provided by: — I,61 <br /> HOUSING UNIT I"ISPECTION <br /> Comments <br /> Interior Checklist <br /> Okay <br /> Unit has hot and cold running water. ❑Needs Repair* <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑Needs Re air' <br /> []Okay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Repair* <br /> Okay <br /> Doors and windows are accessible/operable to allow for safe ex ting. ❑Needs Re air* <br /> kay <br /> All rooms are clean and sanitary.No insect/rodent infestations present. ❑Needs Re air* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are NOkay <br /> properly vented,strapped and are maintained in a safe,working order. ❑Needs Repair* --- <br /> All smoke and carbon monoxide detectors are present and tested to be shown ❑Needsay <br /> Repair* <br /> in workingorder. r�dkay <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Repair* <br /> [Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Re air* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Needs Repair* <br /> FRoofis <br /> alls,ceilings are free from holes,are not sagging or buckling,have ❑NeedskRepair' <br /> aks and are clean and in good condition. Comments <br /> Checklist [aOkay <br /> perly maintained with no holes,loose shingles,leaks,etc. ❑Needs Repair* --- <br /> UROkay <br /> Exterior siding Is maintained with no loose plaster,peeC g paint,holes,etc. E]Needs Re air* <br /> NOkay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. [_1 Needs Re air' — <br /> kay <br /> Propane tank has barrier protection and"No Smoking'signage. ❑Needs Re air' <br /> [5Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Repair* <br /> kay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* --- <br /> 120kay <br /> The gas fuel connection is as approved and safe. ❑Needs Repair* <br /> [Okay <br /> There are no insect or rodent infestations. ❑Needs Re air* <br /> Okay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Re air' <br /> *Needs Repair:Please specify date repairs to be completed.An Buildin Permits required for repairs must be obtained and finaled. <br /> I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. <br /> SIGNED: DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />