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S A N J O A Q U I N Environmental Health Department ---COUNTY---- DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: ! S PR#: LOCATION: R, r` " M ESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: 0 ' Date of Inspection: . Type of Housing Unit: eSingle Family Dwelling ❑ Mobile Home ❑Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: j Gas Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. kay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. Okay ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters), Okay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. okay ❑N eds Repair* All rooms are clean and sanitary.No insect/rodent Infestations present, Okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are Okay 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 kay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ❑Needs Repay air* All plumbing in safe,working order(no leaks,properly maintained). 5itbkay ❑Needs Re air' All counters,sinks,toilets,tubs,showers are working and in sanitary condition, �ROkEl Needs Repay air* All floors,walls,ceilings are free from holes,are not sagging or buckling,have Obkay 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, kay ❑Needs Repair* WUka Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, ❑Nees Re air* Stairways are safe with no rotting,deteriorating,or loose parts. Okay ❑Needs Repair* Propane tank has barrier protection and"No Smoking"signage. kay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. toOkay ❑Needs Repair* . The electrical panel is covered and protected from tampering. gatkay ❑Needs Repair* The gas fuel connection is as approved and safe. kay - ❑Needs Re air* There are no Insect or rodent Infestations. ffokay ❑Needs Re air* The sewage system Is functioning,with no surfacing wastewater or backup, A20[I Needs Repkay air" *Needs Repair:Pleasespecify date r airs tP459ccmpleted.Any Building Permits required for repairs must be obtained and finaied. 1 certify thajlAtt7e inspected the ab a no a nit and that the information provided is true and correct to the best of my knowledge. SIGNED: �. 41 7 ' DATE TITLE 68 . Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com