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I \ S A N J O A Q U I N Environmental Health Department —C O U N T Y----- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: 1 PR#: > LOCATION: 'r✓�d MAP DESIGNATION: HOUSING UNIT INFORMATION _ Address or identification number of unit: Date of Inspection: Type of Housing Unit: batingle Family Dwelling ❑ Mobile Home ❑ Other: #Employees in Unit: i Date Unit First Built or Installed: Electrical Power Provided By: ( Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. Lrkay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. Wkay ❑Needs Repair* Heater maintained in functioning and safe manner(No spare/portable heaters), EtTik❑Needs Repay air* Doors and windows are accessible(operable to allow for safe exiting, Q-6kay ❑N eds Repair* All rooms are clean and sanitary.No Insect/rodent Infestations present. Ly kay Needs Re air* All appliances(stove,water heaters,air conditioning units,heaters)are JROkay roperly 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 Wkay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). CROkay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained), Okay ❑Noe Noeds 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 Rbkay 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. Wkay ❑Needs Repair* _ Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, p E�OkNeeds Repair*air* Stairways are safe with no rotting,deteriorating,or loose parts. -*Okay —. ❑Needs Repair* _ Propane tank has barrier protection and"No Smoking"signage. Okay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. Okay ❑Needs Repair . The electrical panel is covered and protected from tampering. Okay - ❑Needs Repair* The gas fuel connection is as approved and safe, MOkay ❑Needs Repair* There are no insect or rodent Infestations. Q4kay ❑Needs Repair* The sewage system is functioning,with no surfacing was t ater or ba kup, l;�Okay ❑Needs Re air* *Needs Re ai•Pleasespecify date ro4airs to b • n leted.An B,ildin2 Permits required for repairs must be obtained and finaled. I certify that Inspected the ab .noted u t d that the information provided is true and correct to the best of my knowledge. SIGNED: DATE L (� 'rr[TLE 186 rlazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcelid.com