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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: // i' PR#: <br /> LOCATION: I/I/. t� U MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION _ <br /> Address or identification number of unit: Date of Inspection: ;O/ <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 /> Comments <br /> Interior Checklist <br /> BOkay <br /> Unit has hot and cold running water. ❑Needs Re air* <br /> Okay <br /> Approved electrical power and gas fuel being supplied to Unit. ❑N eds Re air* <br /> POkay <br /> Heater maintained in functioning and safe manner(No space/portable heaters). ❑NIe�eldnk <br /> s Repair* <br /> ay <br /> Doors and windows are accessible/operable to allow for safe exiting. El Needs Re air* <br /> kay <br /> All rooms are clean and sanitary.No insecilrodent infestations present. ❑N eds Re air' <br /> All appliances(stove,water heaters,air conditioning units,heaters)are [ Dkay <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 [INe8edskay <br /> Repair' <br /> in workingorder. <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ElN edskRey <br /> air* <br /> (Okay <br /> All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Repair* <br /> Okay <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑N eds Repair* <br /> All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs Repair* <br /> no water leaks and are clean and in good condition. Comments <br /> Exterior Checklist <br /> kay <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Repair* ----- <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ElNeeedk <br /> Rkay <br /> e air* <br /> Okay <br /> Stairways are safe with no rotting,deteriorating,or loose parts. ❑ eeds Repair*.. <br /> Okay <br /> Propane tank has barrier protection and"No Smoking'signage ±E1 <br /> Needs Repair* <br /> Okay <br /> The trash cans are sufficient in size,have lids and are picked up weekly. Needs Repair* <br /> I Okay <br /> The electrical panel is covered and protected from tampering. ❑Needs Repair* <br /> [Okay <br /> The gas fuel connection is as approved and safe. ❑Needs Re air* <br /> )Okay <br /> There are no insect or rodent infestations. ❑Needs Re air* <br /> kay <br /> The sewage system is functioning,with no surfacing wastewater or backup. ❑Needs Repair* <br /> *Needs Re air:Please specifv 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 uni-and that the Information provided is true and correct to the best of my knowledge. <br /> SIGNED: V-I, <br /> DATE TITLE <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />