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SAN J O A Q U I N Environmental Health Department <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: Gc �e%�i ��/ 1��✓G PR#: <br /> LOCATION: `/C/ MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: <br /> Type of Housing Unit: 4 Single Family Dwelling ❑Mobile Home ❑Other: <br /> #Employees in Unit: Date Unit First Built or Installed: <br /> Electrical Power Provided By: -2C �- Gas Provided bar: �= <br /> HOUSING UNIT INSPECTION <br /> Interior Checklist Comments <br /> Unit has hot and cold running water. ®Okay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. BOkay <br /> ❑Needs Repair* <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ®okay <br /> ❑Needs Repair* <br /> Doors and windows are accessible(operable to allow for safe exiting. (Okay <br /> ❑Needs Repair* <br /> All rooms are clean and sanitary.No insectfrodent infestations present. POkay <br /> ❑Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are Qokay <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 ,jOkay <br /> in working order. ❑Needs Repair" <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). kay <br /> ❑Ne ds Re air' <br /> All plumbing in safe,working order(no leaks,properly maintained). kay <br /> Ele ds Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. JZ�okay <br /> ❑Needs Repair' <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ,{Okay <br /> no water leaks and are clean and in good condition. ❑Needs Repair' <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. Okay <br /> ❑ ds Re air" <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. LjOkay <br /> ❑Needs Repair* <br /> Stairways are safe with no rotting,deteriorating,or loose pads. Okay <br /> ❑Needs Re air` <br /> Propane tank has barrier protection and'No Smoking'signage. kay <br /> ❑Needs Repair* <br /> The trash cans are sufficient In size,have lids and are picked up weekly. Okay <br /> ❑Needs Repair* <br /> The electrical panel is covered and protected from tampering. Okay <br /> E] ds Re air' <br /> The gas fuel connection is as approved and safe. Okay <br /> ElNeeds Repair* <br /> There are no insect or rodent infestations. DOkay <br /> El Needs Repair* <br /> The sewage system is functioning,with no surfacing wastewater or backup. El NeeOkayds air" <br /> "Needs Repair:Pleasespecify date repairs to be completed.Any Building 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: <br /> DATE TiT E <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />