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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: r '' PR#: LOCATION: MAP DESIGNATION: HOUSING UNIT INFORMATION 1 Address or identification number of unit: Date of Inspection: Type of Housing Unit: Zsingle Family Dwelling ❑ Mobile Home ❑Other: #Employees in Unit: 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, fg6kay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. WOkay ❑Needq Repair* Heater maintained in functioning and safe manner(No space/portable heaters), Pokay ❑Needs air* Doors and windows are accessible/operable to allow for safe exiting, kay ❑Needs 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 R6kay 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 okay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets), kay ❑Needs Re air* All plumbing in safe,working order(no leaks,properly maintained), kay ❑Nees 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 itkay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist tgOComments Roof is properly maintained with no holes,loose shingles,leaks,etc. kay ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. 1210kEl Needs Repay air* Stairways are safe with no rotting,deteriorating,or loose parts, ff0kay ❑Need6 Repair* Propane tank has barrier protection and"No Smoking"signage, kay ❑Nees Repair* The trash cans are sufficient In size,have lids and are picked up weekly, Okay ❑Need Repair- The electrical panel is covered and protected from tampering. kay ❑Needs Repair* The gas fuel connection is as approved and safe, 2rOkay ❑Ne ds Repair* There are no Insect or rodent Infestations. Okay _ ❑Needs Repair* The sewage system Is functioning,with no surfacing wastewater or backup, Okay ❑Needs Repair* *Needs Repair:Pleasespecify ditto repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. 1 certify t ave inspected thq.,ebove r nd that the information provided is true and correct to the best of my knowledge. SIGNED: %•/J ��`� �� a I;,,� �/' DATE WTITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com