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SAN JOAQUIN Environmental Health Department --COUNTY DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAAME: �r Z to �F G PR#: LOCATION: /0IW AN/h f Gti1` L" r �!� T,j) AP DESIGNATION: HOUSING UNIT INFORMATION ate of Inspection: Address or identification number of unit: � D_ — Type of Housing Unit: Single Family Dwelling ❑ Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: Gas Provided by: HOUSING UNIT INSPECTION Comments Interior Checklist Okay Unit has hot and cold running water. ❑Needs Repair* Okay Approved electrical power and gas fuel being supplied to Unit. ❑Nees Re air* Okay Heater maintained in functioning and safe manner(No space/portable heaters). ❑Needs Repair. Doors and windows are accessible/operable to allow for safe exiting. ElWedskRey air* f0Okay All rooms are clean and sanitary.No insect/rodent infestations present. ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are [20kay 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 ❑Needs kay Repair* in workingorder. Okay All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Re air* kay All plumbing in safe,working order(no leaks,properly maintained). ❑Needs Re air* Okay All counters,sinks,toilets,tubs,showers are working and in sanitary condition. ❑Needs Re air* All floors,walls,ceilings are free from holes,are not sagging or buckling,have ❑Needs Repairno water leaks and are clean and in good condition. Comments Exterior Checklist Okay Roof is properly maintained with no holes,loose shingles,leaks,etc. ❑Needs Repair- Exterior e air*Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ElNeedskRey air* 20kay Stairways are safe with no rotting,deteriorating,or loose parts. ❑N eds Re air* kay Propane tank has barrier protection and"No Smoking'signage. ❑Needs Repair* ]Okay The trash cans are sufficient in size,have lids and are picked up weekly. ❑Needs Repair* kay The electrical panel is covered and protected from tampering. ❑N eds Re air* kay The gas fuel connection is as approved and safe. ❑N eds Re air* kay There are no insect or rodent infestations. ❑Needs Re air* kay The sewage system is functioning,with no surfacing wastewater or backup. ❑ Peds Repair* *Needs Re air:Please specifv date repairs to be completed.Any Building Permits required for rc airs must be obtained and finaled. 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. -- SIGNED: ——�,- 0 - 3L DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com