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SAN JOAQUIN Environmental Health Department <br /> --C O U N T Y---- <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: adA 1 -c PR#: <br /> LOCATION: �/ A MAP DESIGNATION: <br /> HOUSING UNIT INFORMATION <br /> Address or identification number of unit: Date of Inspection: , <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 /> Interior Checklist Comments <br /> Unit has hot and cold running water. CWkay <br /> ❑Needs Repair* <br /> Approved electrical power and gas fuel being supplied to Unit. 00kay <br /> ❑Need,Re air* <br /> Heater maintained in functioning and safe manner(No space/portable heaters), ❑Needs Repair* <br /> Doors and windows are accessible/operable to allow for safe exiting, kay <br /> ElN eds Repair* <br /> All rooms are clean and sanitary.No Insect/rodent Infestations present. b4may <br /> ❑Needs Repair* <br /> All appliances(stove,water heaters,air conditioning units,heaters)are kay <br /> properly vented,strapped and are maintained in a safe,workingorder, [INee s Repair* <br /> All smoke and carbon monoxide detectors are present and tested to be shown Wkay <br /> in workinq order. ❑Needs Repair* <br /> Wka <br /> All wiring in safe,working order(no splices,exposed wires,uncovered outlets), ❑Nees Re air* <br /> All plumbing in safe,working order(no leaks,properly maintained). Okay <br /> ❑Needs Repair* <br /> All counters,sinks,toilets,tubs,showers are working and in sanitary condition, jl�jOkay <br /> ❑Needs Repair* <br /> All Floors,walls,ceilings are free from holes,are not sagging or buckling,have Ciekay <br /> no water leaks and are clean and in good condition. I ❑Needs Repair* <br /> Exterior Checklist Comments <br /> Roof is properly maintained with no holes,loose shingles,leaks,etc. kay <br /> ❑Needs Repair* <br /> Exterior siding is maintained with no loose plaster,peeling paint,holes,etc, [:1 Needs Repay air* <br /> Stairways are safe with no rotting,deteriorating,or loose parts, j�4kay <br /> Elee s Repair* <br /> Propane tank has barrier protection and"No Smoking"signage, Okay <br /> ❑Needs Repair* <br /> The trash cans are sufficient in size,have lids and are picked up weekly. IROkay <br /> ❑Needs Repair* . <br /> The electrical panel is covered and protected from tampering, Wkay <br /> ❑Needs Repair* <br /> The gas fuel connection is as approved and safe, Wkay <br /> ❑Needs Re air* <br /> There are no insect or rodent Infestations. Okay <br /> ❑Nee4 Repair* <br /> The sewage system Is functioning,with no surfacing waste er or backup, ❑Needs ay Repair* <br /> *Needs Repair:Pjapse specify dater airs to be completed.An Building Permits required for repairs must be obtained and finaled. <br /> I certify that 111 spected the ab9wnoted u ' . nd that the Information provided is true and correct to the best of my knowledge. <br /> SIGNED: ��� I� �� j_ A" <br /> DATE✓ TITLE�'� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />